In 2017, NHS Improvement commissioned a review into the maternity services at the Shrewsbury and Telford Hospital NHS Trust (SATH), on the instruction of the then-Health Secretary, Jeremy Hunt MP. The review is being conducted by Donna Ockenden. Donna is a Senior Midwife and Advisor within the NHS. She has a wealth of experience in maternity issues, and has conducted similar reviews in the past. Donna is working with a team of clinical staff, and together they are reviewing the standard of the maternity services provided at SATH.
How many cases are they looking at?
Initially, Donna and her team were reviewing 23 cases. As time went by, the number of families contacting the team to have their cases considered grew significantly, and the review is now looking at a total of 1,862 cases. A number of these cases were put forward for consideration by the Trust itself, after it had carried out its own review.
How many cases have they looked at to date, and why are they releasing this report now?
To date, 250 cases have been fully reviewed by the team. The concerns raised by the families who spoke to Donna, and the concerns that have arisen from the 250 completed cases, have led the review team to completing an ‘Emerging Findings’ report. It was agreed with the Minister of State for Mental Health, Suicide Prevention and Patient Safety that this early report would be released now, in order for light to be shed on these concerns as soon as possible, in the hope that improvements can be made whilst the review team continue to work their way through all of the other cases.
What does the report say?
The report highlights a number of concerns, which appear to form a recurring theme in the 250 cases that have been reviewed so far.
In the event of something going wrong, clinicians at the Trust seem too keen to blame parents for what has happened. A ‘blame culture’ within parts of the Trust, pointing outwards at parents, appears to exist.
This is compounded by a lack of compassion and kindness being displayed in several cases. The conversations held with parents and the wording used within patients’ records are evidence of a lack of understanding of what patients are going through. This is particularly the case where a bereavement is suffered; parents describe instances of no support, or instances where matters are actually made worse by the clinical staff.
A paternalistic approach to treatment and advice has also been found. A lack of informed consent, and a tendency to favour vaginal births over caesarean sections demonstrate this. There appears to be an excessive use of Oxytocin to speed up vaginal deliveries, often resulting in problems occurring. Rather than carry out a caesarean section, clinicians seem to favour vaginal deliveries, even when it doesn’t seem safe to do so. The use of forceps to deliver babies via vaginal delivery is also criticised, with excessive force leading to traumatic births and injuries including shoulder dystocia, fractured skulls and cerebral palsy. The Trust has a reputation locally for favouring vaginal deliveries, with figures showing that they regularly carry out 10% less caesarean sections than average. This obsession with a ‘normal delivery’ having to be a vaginal delivery, with mothers being kept in the dark as to how and where they give birth, has to stop.
The training of staff at the Trust also comes under scrutiny, as midwives are (in the 250 cases reviewed) regularly failing to provide the standard of care that would be expected of a reasonable midwife. Problems with monitoring the fetal heartrate, either by intermittent auscultation or by CTG, are contributing to unnecessarily poor outcomes for families. When a ‘complex’ case arrives, there is also often a failure to escalate the case to someone more senior.
Finally, when things do go wrong, lessons are not being learned. Investigations into adverse incidents appear to be haphazard; often not carried out, often carried out to only a cursory standard. Families are being left without answers and without any reassurance that what they have gone through will not be happening to anyone else.
What are the recommendations?
The review team have made a number of recommendations at this stage:
● An increased level of training for staff, as well as increased communication between staff and a higher degree of input from Senior Consultants.
● The creation of a Midwifery and an Obstetric Lead at the Trust, to champion and improve fetal monitoring. These individuals would provide regular training and increase the standards expected within the maternity team.
● External (outside the Trust but within the region) investigation of Serious Incidents, with investigations being mandatory in cases of fetal, maternal and neonatal death and cases of neonatal brain injury. Trusts are expected to take a collaborative approach to sharing and learning from mistakes.
● The creation of Independent Advocates for Patients and Patients’ Families. The Advocates would provide a further voice for patients, and would have direct contact with the Trust Board.
An increased focus on informed consent. Patients must be told of the risks and benefits of their treatment options, and that advice must change if appropriate. Regular risk assessments should be carried out to ensure that if the risks/benefits of treatment options change, the patient is informed of this and is able to make an informed decision as to what they want to do.
What Will Happen Now?
Donna and the team will continue with their mammoth efforts to conduct what is one of the largest reviews of its kind in NHS history. The families that have been affected will read through and digest the report over the coming days and weeks, and will no doubt welcome the full report, which is expected next year. We would like to thank Donna and her team on behalf of the clients that we represent and who have been affected by the issues raised in the report, for their continued hard work and dedication to improving patient safety at SATH and within the NHS.
The report begins with a letter from Donna, acknowledging the difficulties faced by the NHS generally, let alone in what has been a very challenging 2020. Despite those challenges, the issues raised must now be faced head on. A real opportunity for improvement is on offer as a result of the report, which must be grasped. The sooner the recommendations are implemented, the sooner that patient safety is improved and the sooner that lives are changed for the better. The report says ‘over the years, many important recommendations from previous national maternity reviews and local investigations which might have made a significant difference to the safety of mothers and babies receiving care at the Trust have either not been implemented or the implementation has failed to create the intended effect of improving maternity care’; for the sake of all those affected, let this not be another wasted opportunity.