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The final report of the Ockenden Maternity Review has found that Shrewsbury and Telford Hospitals NHS Trust ‘failed to investigate, failed to learn and failed to improve and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives’.
The size and scale of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, led by midwifery expert, Donna Ockenden, is unprecedented in NHS history. The review investigated the harrowing experiences of more than 1400 families which led to death and life-changing injury for hundreds of mothers and babies.
Building on the ‘Immediate and Essential Actions’ for maternity services recommended in its first report the final report makes a further 84 recommendations. More than 60 of these involve action that must be taken by the Trust to ensure that maternity services are run and provided safely, setting out what Donna Ockenden recently called a ‘blueprint of care’. The report warns that, going forward, the Trust must deliver maternity care ‘recognising that there will be an ongoing legacy of maternity-related trauma within the local community, felt through generations of families’.
What did the Ockenden Review find?
The review report highlights, in a series of short patient case summaries and quotations, the multiple ways in which mothers and babies were repeatedly failed by the Trust at every level of their care. Each stillborn or injured baby and each maternal injury or death has had a profound and permanent impact on the individual and their family. The report found that many of these injuries would have been avoided with better care.
None of the 12 mothers who died had received good care and nine of them would have had a different outcome if their care had been significantly improved. The review team noted the relatively high number of direct maternal deaths at the Trust. The review team also had significant and major concerns about the care received by a quarter of the 614 women who experienced other types of serious injury or adverse outcomes, such as severe sepsis, major haemorrhage, eclampsia or cardiac arrest.
One in four of the 498 babies who were stillborn might have had a better outcome but for significant or major concerns about their maternity care. Of the babies who were born alive but then died within a few days of life (neonatal death) nearly a third might have had a different outcome with better care.
There were significant and major concerns about the maternity care given to the mothers of two thirds of the 44 babies who suffered HIE brain injury. In some cases, there were also concerns about their therapeutic cooling. HIE from oxygen deprivation at birth is a known cause of cerebral palsy. The review also found major maternity care failings affected the outcome of 40% of babies who did not have HIE, but had cerebral palsy from other causes.
The report highlights multiple failings which regularly occurred at each stage of maternity care; antenatally, during labour, during childbirth and postnatally.
A few of the many common themes included the lack of consultant involvement either in reviewing high risk women on their admission to hospital, on ward rounds or when complications occurred which required escalation. In fact, many women underwent induction of labour without any medical review at all, or on the antenatal ward instead of the labour ward increasing their existing high risk status.
Escalation of women in high risk or complex cases to more senior or specialty staff didn’t take place or was delayed because the doctor or supervisor was too busy, the risks weren’t recognised or escalation was not possible given the unsupportive culture. Senior clinicians failed to respond when called and midwives who asked their colleagues for assistance were ridiculed for not knowing how to look after a woman in labour. There was a high reliance on locums, who received no supervision or support, resulting in poor standards of care.
The review found that staff were over-confident in their ability to manage complex pregnancies and babies diagnosed with fetal abnormalities during pregnancy, resulting in a reluctance to refer the mother to a tertiary unit for specialist care. The neonatal unit at one hospital within the Trust even continued to operate as a neonatal intensive care unit (NICU) for many years after it had been downgraded to a local neonatal unit.
Misinterpretation and lack of action on abnormal CTGs and delayed giving of antibiotics for early prolonged rupture of membranes were among countless examples where the standard of care did not follow national guidelines.
The review found failings by the Trust at every level, including governance (management, decision making and accountability), culture and quality of care. Serious harm to mothers and babies, including their deaths, were not properly investigated or reported, and repeated errors failed to result in learning or improvements in care. The Trust hid its mistakes from families who suffered injury or loss of mothers and babies, dismissing their concerns and even blaming the mothers for the harm. In addition, failure by external organisations, including the NHSLA (now NHS Resolution) and the Care Quality Commission, to effectively monitor and hold the Trust accountable for its maternity safety failings contributed to the prolonged period of over 20 years during which mothers and babies were being severely harmed.
“Throughout our final report we have highlighted how failures in care were repeated from one incident to the next. For example, ineffective monitoring of fetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved. There was a tendency of the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the Trust was not held to account by external bodies.” Donna Ockenden.
What happens now
Responding to the report in a statement to Parliament, the Secretary of State for Health and Social Care said that the Trust, NHS England, and the Department of Health and Social Care will be accepting all 84 recommendations made by the review. He commented that the failures of care and compassion that are set out in the report have ‘absolutely no place in the NHS’. He told MPs that some of those who worked at the Trust at the time of the incidents have now been suspended or struck off from the professional register, and members of the Trust’s senior management have been removed from their posts.
In addition, the police are pursuing a criminal investigation, known as Operation Lincoln, into 600 incidents at the Trust.
Call for culture change in maternity safety as hundreds of families left suffering their loss
The Ockenden Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust has shone a light on the suffering that has been caused to thousands of families by decades of mismanagement, deceit and shameful lack of care. Bullying of staff, negligent patient care and arrogant disregard for the standards and guidelines by which NHS care is supposed to operate all became normalised. Incidents causing serious harm were then knowingly ignored, downplayed to avoid reporting and external oversight, and hidden from patients and their families, adding insult to their injury. An unchecked toxic culture led to hundreds of families mourning the loss of mothers and children, and others suffering traumatic physical and psychological injury leaving many needing lifelong care.
Within a learning NHS the Ockenden Review and the scale of needless suffering that it has exposed should be a watershed moment. The learning from this review should be such that there can be no turning back to the old ways. It should now be clear that secrecy in investigations of patient safety only allows problems to continue and increases both staff and patients’ pain.
With hospital scandals continuing to feature in the news, we welcome the Ockenden Review’s call for urgent and immediate action by the Trust, the wider NHS and the government to ensure that this appalling tragedy will never be allowed to happen again.
If you have suffered serious injury or bereavement as a result of negligent maternity care and would like to find out more about making a claim, you can talk to one of our solicitors, free and confidentially, by contacting us here.
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