The Ockenden report on maternity services at the Shrewsbury and Telford NHS Trust is damning. Nearly 300 babies died or were born brain-damaged and over a dozen mothers died due to poor care. The Trust often blamed mothers for the avoidable deaths. The report also found that many women were made to have natural births who should have had a Caesarean section. The SaTH received the long-awaited report on Wednesday covering an investigation into the last 20 years of maternity care in Shropshire. Repeated failures, as well as care that did not follow best practice, led to hundreds of deaths and injuries. Senior midwife, Donna Ockenden, carried out an in-depth investigation involving nearly 1,500 families, most of whom were in the care of the SaTH between 2000 and 2019.
As part of the investigation, 498 stillbirths were investigated and the report found that one in four babies may have lived had adequate care been provided. The investigation team also uncovered serious failings in maternity care including an unwillingness to listen to families, a slowness to learn from mistakes, and the failure of external bodies to improve the maternity services at SaTH over two decades.
In addition, the report found that the Trust, in many cases, did not investigate incidents, even deaths.
Where investigations did take place, they did not meet inquiry standards of the time while also failing to identify ways to improve maternity services.
Ockenden report welcomed by campaigning families
After losing baby Kate in 2009 and baby Pipa in 2016, parents Rhiannon Davies and Richard Stanton and Kayleigh and Colin Griffiths spearheaded a campaign calling for an investigation into the Shropshire maternity services. Speaking to Sky News, Richard Stanton said:
“This has to be a watershed moment for maternity care across this country that a tragedy of this scale can never be allowed to happen again.
“Those who are in charge of policy need to make sure that policy is put in place and tested to make sure that this never happens again and also that bereaved parents are not at the forefront of having to uncover such tragedy.”
A string of failures in SaTH NHS Trus maternity care
In the interim report that was published in December 2020, Ockenden’s team already highlighted catastrophic failures. Among them, was the Trust’s unwillingness to carry out investigations and make improvements in care in the aftermath of failures. The team also uncovered that families were not included in investigations with some even blamed for their tragedies.
Ockenden also uncovered a Caesarean section rate that is considerably lower than elsewhere in the UK.
Speaking at the publication of the final report, Ms 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, mothers 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.”
“Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require.”
60 recommendations with 15 to be implemented immediately
A large proportion of the Ockenden report outlines recommendations to improve maternity services at the Trust 15 of which are to be implemented immediately. Levels of staffing, staff training, learning from past mistakes, proper care and involvement of families are but a few of these recommendations.