Following on from her first report in December 2020, Donna Ockenden, Chair of the Independent Maternity Review, has published her final report dated 30th March 2022 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”.
What did Donna Ockenden’s first report say?
The first report identified evidence that concerns at The Shrewsbury and Telford NHS Trust were not appropriately escalated, leading to a direct impact on the safety and quality of care provided to women and their babies. The first report made seven essential recommendations:
- Strengthen maternity units by increasing partnerships between Trusts and local networks
- Women and their families are listened to with their voices heard
- Staff who work together must train together
- Robust pathways must be in place to manage complex pregnancies
- Women must undergo a risk assessment at each contact throughout their pregnancy pathway
- All maternity services must appoint a dedicated lead midwife and lead obstetrician to champion best practice in fetal monitoring
- Women must have access to accurate information to enable informed choice about place of birth and mode of delivery including choice for a C-Section
Following the publication of the first report, there seemed to have been some improvements in the maternity services at The Shrewsbury and Telford NHS Trust. However, by the time the second report by Donna Ockenden was published, there remained concerns that their NHS maternity services are still failing to adequately address and learn lessons from serious maternity events.
What was the purpose of the second report by Donna Ockenden?
Donna Ockenden’s second report builds on her initial report. The review team has highlighted both a failure to learn and a lack of progression at The Shrewsbury and Telford NHS Trust in terms of governance and learning across the timespan of the review. The review owes its origins to Kate Stanton Davies, her parents Rhiannon Davies and Richard Stanton, together with Pippa Griffiths and her parents Kayleigh and Colin Griffiths, who tragically suffered the loss of their babies at The Shrewsbury and Telford NHS Trust. The review started with 23 families, but it grew to include reviews of 1,498 families and their tragic experiences between 2000 and 2019.
The report consists of a review of a total of 12 cases of maternal death, 498 cases of stillbirth, 85 cases of Hypoxic Ischaemic Encephalopathy (HIE), 488 cases of neonatal death reviews, and 286 reviews of cerebral palsy cases, which were all considered by the review team.
What were the findings of second report?
In summary, Donna Ockenden reports that The Shrewsbury and Telford NHS Trust failed to investigate, failed to learn and failed to improve and, therefore, failed to safeguard mothers and their babies at one of the most important times in their lives.
The report reveals that 201 babies could have survived had Shrewsbury and Telford NHS Trust provided better care, including the 9 mothers that sadly lost their lives. There were 70 neonatal deaths and 131 cases where babies were stillborn negligently. There were also 29 cases where babies had suffered from severe brain injuries and there were 65 reports of cerebral palsy. This has resulted in tragedies and life-changing incidents for so many families.
What specific failings were identified?
Donna Ockenden has reported a number of issues that should have been acted upon to provide better care and outcomes including:
- Ineffective monitoring of foetal growth and heart rate.
- Lack of communication between the midwives and the laid-back approach of not escalating matters to senior members of staff
- Lack of consultant led reviews, and, in some cases, consultants had not even been involved in the care
- Culture of reluctance to perform caesarean sections which resulted in many babies dying during or shortly after birth
- Repeated failures in the quality of care at the Trust between 2000 and 2019 with mothers and babies dying or suffering from major injuries as a consequence.
- Some babies suffered skull fractures, broken bones, or developed cerebral palsy after traumatic forceps deliveries.
- Record keeping – the Trust had kept important clinical information on post-it notes which were more than likely to have been sometimes cleaned up and placed into the bins.
- Lack of staff and ongoing training
- Lack of effective investigations and governance which resulted in lack of active learning from mistakes
- Culture of not investigating complaints and not listening to the families involved. Between 2011 and 2019, 40% of stillbirths and 43% of neonatal deaths did not have an investigation.
- Where cases were examined, responses were described as lacking transparency and honesty. There was also a lack of compassion and kindness whereby there was very limited support given to bereaved families and specifically young adults.
- A culture of bullying, anxiety and fear of speaking out among staff at the Trust
One of the many conclusions was that mothers had not received care in line with best practice at the time. Only one maternal death investigation was conducted by external clinicians and the internal reviews were poor. The internal investigations did not recognise service and system failings and failed to follow procedures and guidance. Additionally, one of the many criticisms was that in some cases mothers themselves were also held responsible for the poor outcomes.
What were Donna Ockenden’s main recommendations?
Donna Ockenden has identified 60 specific improvements that need to be made at Shrewsbury and Telford NHS Trust, which also includes 15 recommendations for the wider NHS and 3 for the Government. Her report recommends:
- Additional funding to be made available to improve maternity services and training across the NHS
- Family voices to be central in the quality of care being received and as such to employ the role of an independent senior advocate within the maternity services.
- For the Department of Health and Social Care (DHSC) to work with the Royal College of Obstetricians and Gynaecologists, (RCOG) and Health Education England to consider how to deliver a sustainable level of obstetric training posts, to enable Trusts to deliver safe staffing
- A proportion of maternity budgets must be ring-fenced for training in every maternity unit
- For the Trust to make the needs of families affected the primary concern during incident investigations
- Improvements to be made in post-natal care and the care provided to bereaved families. They should feel supported at all times
- A robust process to be in place to ensure that all safety concerns raised by staff at the Trust are investigated
- For timely and independent reviews of serious maternity incidents to ensure lessons are learned and changed implemented effectively.
- The Trust board must review the progress of the maternity improvement and transformation plan every month
- The Trust must also ensure complete and accurate information is given to families after any poor outcome
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