An independent review into maternity services at the Shrewsbury and Telford Hospital NHS Trust has outlined immediate and essential actions required to improve safety in maternity services at the Trust and across England.
The Ockenden Report, an independent review led by midwifery expert Donna Ockenden, published its initial findings on 10 December 2020. A second, final report will follow next year. The review is investigating 1,862 cases of serious incidents including newborn brain injury and deaths of mothers and babies, mostly between 2000 and 2019. The initial findings are based on a review of 250 cases so far. When the review is completed, Ms Ockenden believes it is likely to be ‘the largest number of clinical reviews conducted as part of an inquiry relating to a single service in the history of the NHS.’
The investigation was requested in 2017 by former Secretary of State, Jeremy Hunt, following concerns raised by two bereaved families, whose babies had sadly died following their birth at the Shrewsbury and Telford Hospital NHS Trust.
Key initial findings
- Lack of kindness and compassion
The report states that ‘one of the most disappointing and deeply worrying themes that has emerged is the reported lack of kindness and compassion from some members of the maternity team at the Trust.’ There were cases ‘where women were blamed for their loss and this further compounded their grief. There have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all.’
- Poor management of complex pregnancies
In some cases, the review found evidence of ‘poor consultant oversight of mothers with high-risk pregnancies; they either remained under midwifery-led care or were managed by obstetricians in training without appropriate and timely escalation.’ The report also noted a lack of antenatal multidisciplinary team planning for women with significant pre-existing comorbidities and/or other medical risk factors.
- Failures to escalate concerns
There were ‘repeated failures to escalate concerns for further opinion and review’. In some cases, even when concerns were escalated, ‘they were not then acted upon appropriately or escalated further to the appropriate level.’
- Management of labour
The review found evidence of poor obstetric anaesthetic practice and ‘significant problems’ in the interpretation of CTG traces.
- Not following guidelines for safe operative delivery
There was evidence in a number of cases ‘of repeated attempts at vaginal delivery with forceps, sometimes using excessive force; all with traumatic consequences. There was clear evidence that the operating obstetricians were not following established local or national guidelines for safe operative delivery.’
- A culture to keep caesarean sections low
It seemed that there ‘was a culture within The Shrewsbury and Telford Hospital NHS Trust to keep caesarean section rates low, because this was perceived as the essence of good maternity care in the unit.’ Women ‘appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of delivery.’ In some individual cases, the review found that earlier recourse to a caesarean delivery would have avoided death and injury.
- Poor bereavement care
There were several instances where bereavement care ‘was either inadequate or non-existent, which had a negative impact on the wellbeing of the parents and their overall experiences.’
The review made specific recommendations for the Trust in light of these findings, but also made wider recommendations for the improvement of maternity services across England.
Recommendations to improve maternity services across England
- Enhanced Safety
Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks. Neighbouring Trusts must work collaboratively to ensure that local investigations into Serious Incidents have regional and Local Maternity System oversight.
- Listening to Women and Families
Maternity services must ensure that women and their families are listened to with their voices heard.
- Staff Training and Working Together
Staff who work together must train together.
- Managing Complex Pregnancy
There must be robust pathways in place for managing women with complex pregnancies.
- Risk Assessment throughout Pregnancy
Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway.
- Monitoring Fetal Wellbeing
All maternity services must appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion best practice in fetal monitoring.
- Informed Consent
All Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.
We welcome this independent review and its recommendations for improving maternity services and urge the government to not only invest in changes locally at Shrewsbury and Telford Hospital NHS Trust, but also nationally. This is a real opportunity to do right by mums and babies all over the UK and we hope that the actions outlined in the report improve patient safety in maternity services across England.
The stories in the Ockenden Review are heartbreaking, harrowing, and at times difficult to read. Our thoughts are always with the families who have suffered such devastating loss. They deserve kindness and compassion.
We will continue to campaign for patient safety and fight to obtain answers and justice for victims when things have gone wrong. If you have any concerns about the maternity care you have received, please feel welcome to get in touch with us at email@example.com or on 0114 218 4000.