On 30th March 2022, a comprehensive report into the maternity services at the Shrewsbury and Telford Hospital NHS Trust was released. The team investigating the services was led by Midwife and Nurse, Donna Ockenden. Donna, together with a team of midwives, doctors and various other clinicians, were tasked with producing a report into maternity services at the Trust, with treatment going back more than 20 years.
Why was a report needed into the Shrewsbury and Telford Hospital NHS Trust?
Concerns had been raised about the standard of care provided by the maternity team at the Trust by various patients, including the parents of Kate Stanton-Davies and Pippa Griffiths; two babies who had sadly died at the Trust in 2009 and 2016 respectively. After the two sets of parents could not get satisfactory answers from the Trust, legal action was commenced and the parents started to try and find other similar cases, to see whether they were alone in their concerns. Sadly, they were not. After contact was made with the then-Health Secretary, Jeremy Hunt MP, he requested Donna review a set of 23 cases that had been found, including those of Kate and Pippa.
After the Ockenden report was started in 2017, more families started to come forward with further concerns. By the time the report was finished, 1,486 families were involved. There were 1,592 incidents that were reviewed, dating as far back as 1973 and being as recent as 2020. The incidents included cases of stillbirth, neonatal deaths, maternal deaths and birthing injuries.
What did the Ockenden Report say?
The team carried out an investigation of an unprecedented scale and size. They found a shockingly high number of incidents where poor care had been provided, with a significant number involving concerns in the maternity care which might have resulted in a worse outcome for those involved. Some of the statistics are:
● 12 cases of maternal death were reviewed, and it was found that none had received care that was in line with best practice at the time of the treatment being provided. Three quarters of the cases involved care that could, on review, have been significantly improved.
● 498 cases of stillbirth were reviewed, with 25% being found to have significant or major concerns in the care provided. If the poor care had been avoided it could or would have resulted in a better outcome for those involved.
● A third of the neonatal deaths which were reviewed involved similar concerns about the treatment provided, as well as the effect of that treatment.
One of the main concerns in the report, which has been echoed by many of the patients who shared their stories, was that they were not listened to. Women were counselled towards giving birth by vaginal delivery. A focus on, and terminology surrounding ‘natural’ or ‘normal’ birth often led to women not having caesarean sections, even when a vaginal delivery was unsafe. The Trust’s caesarean section rate was 50% lower than the national average; this was lauded at the time but in truth was a red flag for concern.
What Recommendations did the Ockenden Report make?
A huge number of recommendations were made, including more than 60 for the Trust itself, 15 for the NHS as a whole, and a further 3 for the Government.
The recommendations included a call for communication and planning between the Department of Health and Social Care, the Royal College of Obstetricians and Gynaecologists, and Health Education England to work out how safe and sustainable staffing can be achieved and maintained. It called for a multi-year funding increase for workforce expansion and training. Improved and increased training around issues such as CTG interpretation and the assessment of foetal growth was also requested.
A more robust investigation/learning procedure was recommended; concerns were raised that the Trust had been downgrading incidents of severe harm in order to keep investigations in-house and reduce external scrutiny. The management of the Trust and its culture were both identified as leading causes for the lack of accountability. External investigators were either misled into thinking that the Trust was safer than it was, or did not have the teeth to find out the truth.
Perhaps most importantly for those involved, the report had a common thread of ensuring that the families involved are given a voice. The report recommended that the Trust ensure that patients and families are the primary focus during any investigation into wrongdoing. The report highlighted that the Trust had handled many complaints poorly, with a lack of experienced input and a lack of openness and transparency.
Will the Ockenden Report lead to change?
Our Head of Clinical Negligence, Joseph Norton, thinks: in the short term, the brutally honest answer is no, it won’t. Funding will take time to come through. External organisations and investigators will take time to grow teeth and improve their scrutiny. Damaging cultures within the Trust will take time to cleanse and replace.
Problems haven’t gone away. Instances of poor care were being reviewed from as recently as 2020. Staff had given confidential input to the Report team but in the weeks leading up to the report being published, staff were asking to withdraw their comments from the report; they were either too scared of being identified or had been told to not cooperate with the review team. The recent instances of poor care are worrying, and the unacceptable reluctance to embrace change still pervades.
We know from other Trusts that similar reviews are taking place and that similar reports are likely to be released in the future. Similar reports have, indeed, been released in the past. The same mistakes and the same issues crop up time and time again. Mistakes happen. However it is simply not good enough to not learn from those mistakes.
The apparent lack of change and slow progress will disappoint and aggravate the families involved. But they do have hope: the report has a raft of well-thought out and effective recommendations. The Government has committed to making the changes needed at both a local and national level. Funding will come and staffing will be better resourced. Investigations will improve and learning will follow. Cultures will be cleansed and improvements will be made; in particular, any ideology towards a ‘natural/normal’ birth at all costs needs to be eradicated. The terminology alone doesn’t help as it implies that anything but a vaginal delivery is unnatural or abnormal. It’s not right and not good enough.
The report’s recommendations, when implemented, will effect positive change as at their heart is the common thread of the report itself, a thread which needs to be at the heart of any NHS strategy: to put patients first.