The Ockenden review’s first report into maternity care at Shrewsbury and Telford hospitals has today been published, identifying 34 areas where maternity care should be improved.
The review came about following an investigation into avoidable harm to mothers and babies at Shrewsbury and Telford NHS trust launched in 2017. An inquiry was initially set up to investigate the care received by 23 families. As the investigation progressed it expanded to cover over 1860 family complaints.
We have learned that a drive to avoid Caesarean sections and push for “normal” deliveries over several decades resulted in the death of dozens of mothers and babies led to this overhaul of maternity care across the NHS.
The inquiry into the first 250 cases found that mothers experienced a lack of kindness and compassion from staff and in some cases parents were blamed for what happened to their babies. Some mothers were given drugs to increase the strength and frequency of contractions to speed up labour. When this process was not monitored appropriately, babies were put at risk of brain damage and death. A key finding is that mothers need to have an explanation of the risks that they and their babies face during labour and birth.
Prior to the inquiry, the Care Quality Commission had rated the trust ‘inadequate’, with incidents of poor care not being investigated properly by the trust, which meant that failures were likely going to be repeated.
Once the inquiry into Shrewsbury and Telford hospitals became public, parents whose children died raised concerns about maternity care at other hospitals trusts including East Kent Hospital Trust, and Basildon Hospital Trust, both of which are also subject to inquiry.
The Ockenden Review emerging findings report states that NHS hospitals should be forced to work together on serious incidents, such as the deaths of mothers and babies, as well as brain injuries, with regional hubs providing expert advice. It also said that women’s voices must be heard in maternity services, and the CQC should assess how well women’s views are considered in care.
27 ‘actions for learning’ are identified in the report for Shrewsbury and Telford Hospital NHS Trust and seven ‘immediate and essential actions’ not only for the Trust but for all maternity services across England. The recommendations will be put into place nationally and as a matter of urgency to prevent widespread malpractice that puts mothers and babies at risk.
We await the final report when the entire review has been completed but already it is clear that this review will result in a historic shake-up of maternity service in England.
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