The Ockendon inquiry into how the maternity services at the Shrewsbury and Telford Hospital Trust failed so many families is due to publish its final report on 24 March.
No doubt the authors of the report will hope that their conclusions and recommendations will help to bring closure for some of the bereaved. But the report’s real impact will be judged further down the line once its findings have been translated into active improvement of maternity services throughout the country.
Boards to ask: “Are our maternity units safe?”
The interim report had already identified 7 Immediate and Essential Actions (IEA) for all maternity units and NHS England has created a maternity services assessment and assurance tool to help trusts check their progress against both the IEAs and the 10 maternity incentive scheme safety actions. As the narrative accompanying this tool points out: “Fundamentally, boards are encouraged to ask themselves whether they really know that mothers and babies are safe in their maternity units and how confident they are that the same tragic outcomes could not happen in their organisation.”
Caesarean 20% target ditched
Perhaps a more immediate example of intent to take on board the Ockendon recommendations is the recent announcement by NHS England that the 20% maximum target for caesareans has been scrapped with immediate effect. Among the many criticisms levelled at Shrewsbury and Telford was the reluctance of the maternity unit to deliver babies by caesarean section; indeed, at one point the Trust was singled out for praise for having one the lowest caesarean rates in the country. Although the low number of caesarean deliveries was clearly a matter of some pride, the excessive number of neonatal and maternal deaths revealed by the subsequent investigation resulted as much from poor management of births as it did from ideology.
Removing the cap on caesareans must surely be a sign of a civilised society where the health and welfare of both mother and baby are paramount. Giving birth is one of the most important and life changing events in any woman’s life and having all delivery options available must be reassuring. However, this is simply one tool in the box: ensuring that the maternity team works together as a single, cohesive and supportive unit; that all training, monitoring and mentoring is properly focused; and that mistakes are openly acknowledged and acted upon are all critical to ensure the safety of mothers and babies.
Changing culture takes time
Nonetheless, for some Trusts, improvements will take time: despite the recommendations contained in the first Ockendon Report, and the fact that the hospital remained under investigation, of all the serious incidents logged at Shrewsbury and Telford in July 2021, 45% related to maternity services [BBC website 11 October 2021]. Of course, some of this will be down to being short-staffed but it takes time to change a culture, particularly one that has been blown so far off course.
I am advising some of those affected by the poor care they received at Shrewsbury & Telford NHS Trust. If you have any concerns about the standard of maternity care you have received, I would be happy to chat through the options open to you and see if you have a claim for medical negligence.