Report finds over 200 avoidable baby and maternal deaths at Shrewsbury and Telford Hospitals.

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In the middle of 2021, Jeremy Hunt led a review into maternity care which painted a dark picture of the standards of maternity care in England. Following on from that review, the long awaited Ockenden Report has now been published. The report originates from the commitment of two families to find out what happened to their baby daughters and ensure that changes are made to the safety of maternity care in Shrewsbury and Telford NHS Trust Hospitals. The deaths of these two babies in 2009 and 2016 were both avoidable, which is sadly reflective of many cases that we have been dealing with.

Unlike the 2021 review, this report focuses mainly on Shrewsbury and Telford, but it is familiar reading for clinical negligence lawyers and victims nationally. When it commenced it only covered 23 families’ cases, but this number grew to nearly 1,500, with the incidents occurring between 2000 and 2019. During the investigations all aspects of clinical care in the Trust’s maternity services were considered, including antenatal, intrapartum, post-natal, obstetric anaesthesia and neonatal care. There were 12 cases of maternal deaths and 498 cases of stillbirth.

The review team was asked the following questions:

1.  Did the Trust have in place at the time of each incident mechanisms for the governance and oversight of maternity incidents? Does the Trust have this now?

2.  Were incidents and investigations reported and conducted in line with the time relevant national and Trust policies?

3. Is there evidence of learning from any of the identified incidents and the subsequent investigations?

4. Were families involved in the investigation in an appropriate and sympathetic way?

Nearly a third of all incidents reviewed (1,486) identified significant or major concerns in the maternity care provided, which would have resulted in a different outcome. Of the 12 maternal deaths it was found that all those women did not receive care in line with best practice and in 9 cases their care could have been significantly improved.

There are eery similarities between this report and that of Jeremy Hunt’s committee in 2021. It highlights again a routine failure to investigate, inform and listen. There is a pattern of repetitive poor care in all 1,486 cases reviewed and it is suggested that the Trust missed numerous opportunities for learning and improving the quality of care they provide.

There are also a number of similarities between this report and the investigation into Northern Devon Healthcare NHS Trust in 2016 which was prompted by our own maternity negligence lawyer Oliver Thorne in response to a number of tragic maternity care claims he has dealt with involving that Trust.

Throughout the review period, staff from Shrewsbury and Telford were found to be overly confident in their ability to manage complex pregnancies and babies with foetal abnormalities during pregnancy. This, coupled with a reluctance to refer to a tertiary or specialist unit, delays in treatment and an overall failure to escalate concerns in antenatal and postnatal environments, created a very dangerous environment for expectant families.

Staff when interviewed made reference to a ‘them and us’ culture between midwifery and obstetric staff. These poor working relationships were witnessed by families and there is evidence to suggest this negatively impacted the care provided to families during this time period. Families reported that clinicians were unprepared for follow up briefings, complaint responses contained inaccurate information, or worse, tried to justify actions or omissions in care, some going as far as blaming the families themselves.

Perhaps the most upsetting finding is that a number of these incidents are very similar. It is often reassuring to some victims that NHS trusts learn from the mistakes so that similar events will never happen again, but unfortunately in this report and in other trusts with historical maternity care issues, this is not the case. Even when recommendations are made, change is not implemented and so the cycle of maternity negligence continues.

A number of suggestions are made to assist the Shrewsbury and Telford NHS Trust with making immediate and significant improvements including: appropriate investigation and grading of incidents; job plans for staff; removal of conflicts in investigation; changes to candour and communication; more empathetic and kind complaints handling and better leadership and oversight. The full report can be found at https://www.ockendenmaternityreview.org.uk/

The report concludes that Shrewsbury and Telford NHS Trust failed to learn, improve and safeguard families over a prolonged period of time. In general the report states that maternity care must not slip down the priority list as the country emerges from the COVID-pandemic. The NHS is being given an unrivalled opportunity to change and improve maternity service provisions. If the changes outlined in the reports can be implemented together with necessary funding increases this report states it will reduce “the risk of unnecessary loss of life, injury and resultant heartbreak”.

It is troubling that we are still dealing with concerns about NHS maternity services and the broad failure to address or admit mistakes. Time and time again trusts fail to learn from their errors or the errors of their neighbour hospitals. There remains a staffing crisis across maternity care nationally and there are numerous changes required not just at Shrewsbury and Telford, but across a number of hospitals in England.

Oliver Thorne, who is a specialist maternity negligence lawyer, has been a champion for victims of substandard maternity care nationally. His continued work to give victims a voice and access to justice has led to many changes within the maternity care. If you would like to speak to Oliver or any other member of our specialist team please call us on 0800 037 8020 or email us at [email protected]

The Ockenden Report