The Ockenden Review into the death or serious injury of babies and mothers at the Shrewsbury & Telford NHS Trust maternity unit revealed a shockingly high number of affected families (1486).
Most people following the story probably assumed that this was a real outlier – how can so many individual lives have been ruined over such a long time without any action being taken? But as Donna Ockenden’s current review into Nottingham University NHS Trust’s maternity units has revealed, Shrewsbury was no outlier: she and her team are looking at the files of approximately 1800 families who are thought to have been affected by poor treatment at Nottingham’s Queen’s Medical Centre and Nottingham City Hospital. The announcement that the Trust is now also the subject of a police investigation will have compounded the agony for the families concerned.
Tenacious families uncover extent of maternity failings.
If it wasn’t for the determination of the families involved to find out why their babies died or were injured - and their refusal to take no for an answer - their harrowing tales of poor treatment may never have come to light. They were not alone in their fight for the truth – Trust employees had also repeatedly raised concerns, particularly around inadequate staffing levels, which were ignored. A CQC assessment in 2020 rated the maternity units inadequate with insufficient numbers of staff to provide a safe level of care, poor leadership, and a culture that failed to learn from past mistakes. If this sounds familiar, it is. The same types of criticism were levelled at Morecombe Bay, Shrewsbury and East Kent. Indeed, as Dr Bill Kirkup noted in his review of the failures at East Kent, there was no point in recommending how the Trust could improve as such recommendations were routinely ignored.
The Chief Constable of Nottingham announced that her force would be looking at West Mercia Police’s 2020 investigation of Shrewsbury & Telford to help them frame their investigation and that they would be working closely with Donna Ockenden and her review team. Whether or not the police will uncover sufficient evidence to bring criminal charges against either individuals or the trust remains to be seen but it does give an indication of how seriously the matter is being taken.
Management is ultimately responsible.
The importance of good management in hospitals was brought sharply into focus in the Lucy Letby case where the senior leadership’s failure to listen and act on concerns about her was a cited as a major factor in her being able to continue working on neonatal wards with devastating results. Time and time again, when reviewing cases of poor care, it is almost always poor leadership that sits at the centre of the problem. Most hospitals, and particularly maternity units have a problem with staffing, but the vast majority do a good job under difficult circumstances. The common failings identified by the various reviews into maternity scandals include staff indifference, poor relations between midwives and obstetricians, lack of oversight, inadequate training levels, ideological adherence to 'vaginal delivery good, caesarean delivery bad', a refusal to admit mistakes, lack of transparency, and a reluctance to listen to patients’ concerns. And the common factor in all these scandals? Deficient management.
I have advised many families on the poor maternity care they have received at various hospitals, including Shrewsbury and Nottingham. If you have any concerns about the standard of maternity care you or a member of your family have received, please call me for a confidential chat to see if we can help.