LONDON (AP) — Hundreds of women and their babies suffered “avoidable harm” because Britain’s healthcare system ignored serious concerns raised about some medical treatments, a scathing review into three National Health Service scandals found Wednesday.

Patients were dismissed and overlooked when they complained about three medical interventions: pelvic mesh, which has been linked to crippling, life-changing complications including chronic pain; the anti-epilepsy drug sodium valproate, which has been linked to physical malformations in many children when taken by their mothers during pregnancy; and hormone pregnancy tests such as Primodos, thought to be associated with birth defects and miscarriages.

The review chaired by Julia Cumberlege, a former health minister, said the healthcare system had a “glacial” and “defensive” response to concerns over the treatments.

The report outlined “heart-wrenching″ stories of how the treatments led to “acute suffering, families fractured, children harmed and much else” in hundreds of families. Patients then fought for decades to have their concerns heard.

Cumberlege stressed that it was “truly shocking” that no one knows the true number of people affected.

The report said that hormonal pregnancy tests, which were provided in Britain from the 1950s, should have been banned from 1967 — but they were not fully withdrawn in Britain until 1978.


“Thousands of women and unborn children were exposed to this risk,” she said. “This should not have happened. The system failed.”

“The issue here is not one of a single or a few rogue medical practitioners, or differences in regional practice,” the report said. “It is system-wide.”

The two-year study heard mainly from women whose lives were catastrophically affected. It also took evidence from the NHS, private healthcare providers, regulators and professional bodies, manufacturers, and policymakers.

Cumberlege acknowledged that at a time when the NHS’ response to the COVID-19 outbreak had led to praise, her report would offer uncomfortable reading. But she said the system just wasn’t good enough at spotting trends that gave rise to safety concerns.

The report offered nine recommendations, including a fulsome government apology and the need for separate plans to meet the cost of providing additional care and support to those who have experienced avoidable harm.