The recommendations in Donna Ockenden’s final report will have come as no surprise to those who have been following the heart breaking account of the 1486 families who suffered the loss or serious injury of babies and mothers as a consequence of negligent care by Shrewsbury & Telford NHS Trust maternity services. The final Ockenden Report, released on 30 March 2022, builds on the actions outlined in the first report, but the most striking aspect of Donna Ockenden’s accompanying presentation was her repeated concerns that the Trust’s culture was showing no signs of improving, despite its failures being laid bare.
She noted that, right up to the publication date (March 2022), staff and families were still approaching the review team to tell them of concerns around patient safety and poor standards of care. Some staff, fearful of being identified, said that the Trust had suggested that participating in the review’s ‘Staff Voices’ initiative may implicate them in the ongoing police investigation. Accounts of bullying and cliquey, intimidatory behaviour were also reported, with those who spoke up being made to feel part of the problem. Families’ concerns echoed themes the team has seen repeatedly throughout the review period, specifically a lack of transparency and honesty around mistakes.
Poor culture persists
Given what has happened at the Trust over the past 20 years, and given the reviews into failing maternity services at other hospital trusts, this wilful disregard for staff concerns about patient safety is staggering. Many NHS whistle blowers have had a hard landing when trying to raise the alarm, with several having to defend their claims at employment tribunals. This is a perennial problem: Sir Robert Francis’ report ‘Freedom to Speak Up’, produced in February 2015, noted that many hospital managers were unaware of the scale of the problems relating to patient safety because front-line staff were unwilling to speak up, anticipating a hostile response. Sir Robert dismissed trusts’ defence that whistle blowers’ motives for speaking out were often self-regarding, and rejected suggestions that this was a valid excuse for not investigating concerns.
Independent body to oversee improvement
The abject failure of the Trust’s maternity services is not an isolated incident: reviews into the failings at Morecombe Bay, East Kent, and Nottingham remain deeply etched on the consciousness. Donna Ockenden’s first report was published in December 2020 and it laid out 27 Local Actions for Learning for the Trust itself, and 5 Immediate and Essential Actions for all maternity units across the country, which included necessary cultural changes to promote patient safety. These actions have now been increased to 60 and 15 respectively in the final report.
A transparent, open environment is the only way in which lessons can be learnt and improvements made. It is shocking that, despite the criticism levelled at the Shrewsbury & Telford NHS Trust and the impact on its reputation, the hospital is obviously continuing to ignore the report’s recommendations which include ‘learning from incidents’ and ‘listening to families’. The Ockenden Report calls for the immediate setting up of an independent working group, under the joint leadership of the Royal Colleges, to guide the Maternity Transformation Programme, ensuring that all the Immediate and Essential Actions for improving maternity services at all trusts are implemented. Ms Ockenden’s summary of the need for robust oversight is beyond question: “this investment…must ensure that no other family experiences the many tragedies outlined in our report.”
NHS must not be beyond criticism
The Ockenden Report should – and must – shatter any illusion that the NHS is beyond criticism. The NHS does, for the most part, a very good job, often in very difficult circumstances. However, there is considerable evidence that there is a systemic dislike of criticism and a refusal to acknowledge and learn from past mistakes. This state of affairs is not helped by the semi-beatification of the institution and its transformation to ‘our’ – rather than ‘the’ - NHS. It is impossible for any organisation as big as the NHS to be perfect - however much its supporters wish it to be so - and placing it on a pedestal beyond the reach of its critical friends does it no favours.
I continue to advise a number of families, affected by the poor care they received at Shrewsbury & Telford NHS Trust, on potential medical negligence claims. 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.