Preliminary findings of the review of maternity care provided at The Shrewsbury and Telford NHS Trust (The Ockenden Report)

Donna Ockenden, Chair of the Independent Maternity Review of care provided at The Shrewsbury and Telford NHS Trust, has published an emerging findings report in a bid to improve the safety of mothers and babies whilst the full investigation continues.

This interim report covers the emerging themes and trends identified from 250 fully assessed cases, although since the review commenced the number of families who have reportedly directly contacted the investigation team, together with cases provided by the Trust for review, has now reached 1,862. Actions have been proposed which the team believe need to be urgently implemented to improve the safety of maternity services at The Shrewsbury and Telford Hospital NHS Trust as well as learning that they recommend be shared and acted on by maternity services across England, thus extending its reach beyond the Trust which is the focus of their investigations. The wider recommended actions are reproduced below*.

The interim report highlights some anecdotal evidence from families of lack of care and compassion that is startling in itself, at the same time providing data that highlights the Trust as an ‘outlier’ when compared to similar Trusts, such as in their unusually low caesarean section rate. It is worth quoting from paragraph 4.43 here:

‘The review team came across many cases where women said that they had been aware The Shrewsbury and Telford Hospital NHS Trust wished to keep caesarean section rates low. A typical quote during interviews was that ‘they didn’t like to do caesarean sections’. The review team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of delivery’.

Scrutinising and comparing data between similar Trusts is nothing new: it emerged during the Inquiry into paediatric cardiac surgery in Bristol some 20 years ago. Given the amount of data collected within the NHS why not use it to question why some Trusts are doing ‘better’ (or worse) than others, rather than relying on service users to raise their concerns? Vulnerable women hoping to have a baby near to their home have effectively little choice about where they deliver, and often if they express their concerns these voices are ignored.

Ockenden includes the pledge that ‘having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action. We expect to see real change and improved safety in maternity services as a result of findings from these 250 case reviews and our resultant Local Actions for Learning and Immediate and Essential Actions whilst we continue to work towards completion of the full and final report’.

We await the full review, but lasting meaningful change has to be an imperative to prevent the pain and suffering of parents and babies at what should be their best possible experience of childbirth, regardless of their individual circumstances. Avoidable death and brain injury are not acceptable outcomes for our National Health Service, let alone for those families who have to live with the consequences every day.

*Immediate and Essential Actions to Improve Care and Safety in Maternity Services.

1. enhanced safety
2. listening to women and families
3. staff training and working together
4. managing complex pregnancy
5. risk assessment throughout pregnancy
6. monitoring fetal wellbeing
7. informed consent