People protest in favor of the NHS in London.

Rhiannon Davies, Kayleigh Griffiths, The Independent

At last, the final inquiry into the Shrewsbury maternity scandal has been published. Thanks to the inquiry, led by Donna Ockenden, we now know that poor maternity care led to 295 avoidable baby deaths or brain damage cases at a hospital trust — in what has become the largest maternity scandal to ever hit the NHS. We were two of the families affected. Our daughters Kate Stanton-Davies died in 2009, and Pippa Griffiths in 2016.

The release of the report feels like a huge milestone in a very, very, long journey. It’s been very difficult to get to this point. It can’t be understated — the hurdles you have to jump over; the games that people try to play to knock you off your quest for justice.

There really hasn’t been an appetite amidst regulators, or within the hospital trust itself, for change. There also hasn’t been an inclination to shine a light on the failures, which — speaking as victims of catastrophic failure — we find very difficult to understand. So, we feel really pleased that we’ve got to this point, but equally frustrated that it’s been so tough.

While we are pleased that the report has shone a light on what needs to change, we don’t necessarily believe change will happen that fast — and we can’t be rose-tinted about it. We want to know what level of scrutiny is going to be placed on all of the organisations that receive recommendations from the review.

And, as the review is publicised, we hope that women will be informed that they are right to question what’s going on; they are right to listen to their own bodies and not be closed down by midwives telling them they’ve got a “lazy baby”, or whatever else is casually said.

We hope this report will arm the next generation of mums-and dads-to-be to speak up.

The NHS must now undergo heavy scrutiny, and be held entirely accountable for creating the changes that have come at a huge cost to families like ours — families who are constantly pushed and pushed — and pushed back. There’s also a huge cost — financially, emotionally — to all of us for the work we have put in to seeking justice, and for asking for cases to be investigated. This cost must now create change.

The trauma for our families doesn’t just stop now that the report is out. On the contrary — we are exhausted. The fight that we’ve had to endure to get to this point has taken everything out of us. We’ve needed it to come to an end for our own mental health, our own sanity.

It is heartbreaking to have gone through the death of a child, but then to realise that other families have gone through the same — despite all that should’ve been learnt — is devastating.

It is heartbreaking to have gone through the death of a child, but then to realise that other families have gone through the same — despite all that should’ve been learnt — is devastating. To ministers, we’d like to ask why it has been left to us – bereaved parents — to uncover these failings. Why wasn’t it picked up?

This report will now be our legacy — it is for Pippa and Kate, and for all those other families that have been through the worst thing any of us can ever go through. At least now, our families will have real answers.