In November last year the BBC reported that the number of families alleging poor maternity care at the Shrewsbury and Telford NHS Trust hospitals had risen to more than 215, leading it to comment that: ‘this is shaping up to be one of the biggest crises in maternity care in the history of the NHS.’ The Secretary of State for Health, Matt Hancock, put the Trust into special measures at the same time.
A review panel overseen by NHSI and led by senior midwife, Donna Ockenden, was put in place to investigate the scope of the problem. Since its appointment it has repeatedly widened its inquiry and now includes over 250 families, with some going back as far as 1998, with concerns over the standards of care they received. In a recent development, NHS Improvement (NHSI) has requested details of all cases involving stillbirths, neonatal deaths, and brain-damaged babies, bringing the number of cases under review to over 500.
RCOG dropped from Ockenden scrutiny panel
The review panel has not been without its problems: in February affected parents threatened to pull out of the inquiry due to the inclusion of the Royal College of Obstetricians and Gynaecologists (RCOG) on the scrutiny panel, which in 2017 had decided not to tell regulators about the problems it uncovered in its initial report. Parents stopped short of accusing it of a cover-up but were clearly convinced that RCOG had colluded with the Trust to repress the negative findings. The panel has now been abandoned and Ms Ockenden has recruited a number of independent experts, unconnected with the Trust, for additional support.
More recently, two midwives working at The Princess Royal in Telford have been found guilty of misconduct by the Nursing and Midwifery Council following the death of a four-day old baby at the hospital. It was alleged at the misconduct hearing that neither midwife monitored the baby’s birth adequately nor handed over his care correctly. This is a further symptom of a very wide problem at an error-strewn Trust that appears not only to have lost control of its maternity unit but also lost sight of its patient safety commitment.
Unprecedented number of cases being investigated
The number of cases being inspected is unprecedented in maternity care. No doubt the Ockenden report will get to the bottom of the problem but I suspect that we will simply hear more of the same: staff shortages, poor communication, poor leadership (I am sure it is no coincidence that the chief executive has recently left with an interim replacement being appointed) and funding shortfalls. Obviously errors occur in every hospital but Shrewsbury has, until recently, been very reluctant to acknowledge that it has a problem. It is cooperating with the Ockenden inquiry but, until now, its communication has been marked by an extraordinarily defensive tone which is what led, no doubt, to its refusing to publish the original RCOG report and its protestations that it was improving its procedures and standards of patient care.
More revelations of poor care unearthed
When I last wrote about the problems at Shrewsbury I expressed the hope that no more unpleasant revelations would be unearthed. Sadly they have and, although the Trust is now co-operating with the investigations and has admitted liability in a number of cases, including one on which I am currently advising, the final outcome can only be a very unhappy one for all concerned.
If you have any concerns about the standard of maternity care you have received either at Shrewsbury or any other hospital, I would be happy to chat through the options open to you.