The final report of The Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, led by Donna Ockenden, has been published today (30 March 2022).
It examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents where medical records and family consent was gained.
The Ockenden review found repeated failures in the quality of care and governance at the Trust throughout the last two decades, as well as failures from external bodies to effectively monitor the care provided.
The final report identifies hundreds of cases where the Trust failed to undertake serious incident investigations.
Where investigations did take place they did not meet the expected standards and failed to identify areas for improvement in care.
These combined failings led to missed opportunities to learn, with families experiencing repeated serious incidents and harm throughout the period of the review.
'There was a tendency to blame mothers'
Chair of the review Donna Ockenden, said: “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.
"This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding."
Finding is 'depressingly familiar'
The review team heard women felt a loss of control and power and that they were not being listened to.
This resulted in psychological trauma for themselves and, on occasion, their birth partners.
PIF director Sophie Randall said: "This finding is depressingly familiar.
"It echoes the comments of more than 2,300 women who took part in PIF’s Maternity Decisions survey last summer. Our results show the failings are not limited to a single Trust.
"Only 32% of survey respondents felt they had a supportive conversation with a doctor or midwife and 65% of women did not have enough risk benefit information to make an informed decision about their baby’s birth.
"Respondents to our survey wanted more evidence based-risk benefit information and more supportive conversations with the maternity team.
"Most importantly they wanted to know they had a right to choose and be involved in decisions."
Final recommendations
The final report issues more than 60 specific Local Actions for Learning for Shrewsbury and Telford Hospital NHS Trust covering nine areas:
- Improving management of patient safety
- Patient and family involvement in care and investigations
- Improving complaints management
- Care of vulnerable and high risk women
- Diabetes care
- Multidisciplinary working
- Midwifery-led units and out-of-hospital births
- Staffing, including anaesthetic staffing
- Communication with GPs
In addition 15 Immediate and Essential Actions for all maternity services in England were identified covering ten key areas:
- Financing a safe maternity workforce
- Essential action on training
- Maintaining a clear escalation and mitigation policy when agreed staffing levels are not met
- Essential roles for Trust Boards in oversight of their maternity services
- Meaningful incident investigations with family and staff engagement and practice changes introduced in a timely manner
- Mandatory joint learning across all care settings when a mother dies
- Care of mothers with complex and multiple pregnancies
- Ensuring the recommendations from the 2019 Neonatal Critical Care Review are introduced at pace
- Improving postnatal care for the unwell mother
- Care of bereaved families
The recommendations include ensuring all investigation reports use language that is easy for families to understand.
In addition, the review also calls for NHS England to:
- Invest in a recruitment and retention drive to alleviate pressures in understaffed maternity services
- Invest in training for midwives, support staff and doctors
- Take action to ensure midwives and their medical colleagues want to remain working in the NHS
You can read PIF's Maternity Decisions report, including women's top 5 information needs, here.