Donna Ockenden, Chair of the Independent Maternity Review, has published her emerging findings report following a request made by the government that there be an “Independent review of the quality of investigations and implementation of their recommendations of a number of alleged avoidable neonatal and maternal deaths, and harm, at The Shrewsbury and Telford NHS Trust”.
The report follows a review of 250 cases, which identifies actions which the Review considers should be “urgently implemented to improve the safety of maternity services at The Shrewsbury and Telford Hospital NHS Trust” and acted on by maternity services across England.
One of the many criticisms includes a lack of compassion and kindness. This is described as a “deeply worrying theme”. An illustration of this is taken from a letter sent after discharge which stated, “if you would like to come and have a chat with me about the death of your baby……”. This correspondence expressed no words of condolence or sympathy”
Another example is given of a woman in agony, but was told by staff it was “nothing”. “Staff were dismissive and made her (the woman) feel “pathetic””. This hurt was added to by the obstetrician using “flippant and abrupt language and calling her “lazy””.
The report has made a number of recommendations to be acted on-
- Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks;
- maternity services must ensure that women and their families are listened to with their voices heard;
- staff who work together must train together;
- there must be robust pathways in place for managing women with complex pregnancies;
- staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway;
- 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;
- 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 cesarean delivery.
In an accompanying letter to the secretary of state, the Review states they recognise a need for critical oversight of patient safety in maternity units.
There is a recommendation that this oversight must be strengthened but, of course, this will only be achieved if the preliminary recommendations, identified above, are implemented in full and there is the associated funding provided by the government to ensure no other parents have similar experiences in other maternity units across the country.