The sorry saga of the failings at the Shrewsbury and Telford NHS Trust (STNHST) was subject to continued public scrutiny with the publication of the first Ockenden Report 11 December 2020. What is particularly sobering is the revelation that this is just the first report based on the investigation of 250 cases. Since Donna Ockenden’s team was charged with investigating what had happened at STNHST, it has been contacted by hundreds of families as well being provided with further cases by the Trust. The number now under review is 1,862. As Donna Ockenden notes in her letter to the Secretary of State: “When the review is completed, this is likely to be the largest number of clinical reviews conducted as part of an inquiry relating to a single service in the history of the NHS.” A second report into the additional cases is anticipated at the end of 2021.
Sub-standard maternity care
Ms Ockenden’s report makes for depressing reading. She lists a catalogue of sub-standard maternity care being delivered, supported by some heart-rending evidence from the affected women and their families on the callous way many were treated. The only area that escaped wholesale criticism was the standard of neonatal care which was, generally speaking, felt to be good. The investigation was originally triggered by previous Secretary of State, Jeremy Hunt, after a sustained campaign by parents who had lost babies as a result of poor obstetric care and were demanding answers. All those on the Ockenden team involved with compiling the report were appalled at the evidence before them: lack of kindness and compassion; a dysfunctional maternity care team with a lack of collaboration between midwives and obstetricians and between junior doctors and consultants; poor obstetric anaesthesia practices; lack of experience in using fetal heart monitoring equipment; lack of proper management of complex pregnancies; and an almost obsessive approach to ensuring women delivered ‘naturally’.
Lessons to be learnt locally and nationally
The report’s recommendations have been divided into ‘Local Actions for Learning’ of which there are 27 across maternity care, maternal deaths, obstetric anaesthesia, and neonatal care all relating specifically to STNHST. In addition, there are five ‘Immediate and Essential Actions’ to help improve maternity services across the country: enhanced safety; listening to women and their families; staff training and collaboration; managing complex pregnancy; and proper risk assessment throughout. It is disappointing that, after the Mid-Staffs and Morecombe Bay enquiries (the latter focusing on an abnormal number of still births and neonatal deaths in the Trust’s maternity unit), failings of the sort of magnitude uncovered at STNHST continue to happen. A common theme that emerged from the Ockenden report was the lack of cooperation between the midwives and the obstetricians and consequential lack of oversight and training leading to such fatal errors. Midwives were either not escalating concerns when women got into difficulty or when they did, they were not being escalated to consultants obstetricians even when it was clear their experience was needed.
Poor management reflected in dysfunctional maternity unit
Many of the news features that covered the report’s publication focused on the Trust’s low caesarean rates, the result of midwives encouraging women to have ‘normal’ vaginal deliveries even if there were clear indications that a caesarean would be safer. It seems clear that the low caesarean rate is a symptom of wider problems rather than an ideological commitment to natural childbirth. Regardless, the failures uncovered by Donna Ockenden and her team are a function of a dysfunctional management team from the top down and this is reflected in the unsafe practices and uncaring attitudes of those in, and running, the maternity unit.
I am advising some of those affected by the poor care they received at Shrewsbury & Telford NHS Trust and 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.