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Catastrophic failures found at NHS maternity unit

The findings, conclusions and essential actions from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust (SaTH) were published today. The report found “catastrophic failures” at the Trust may have led to the deaths of more than 200 babies, nine mothers and left other infants with life-changing injuries.

Maternity practices at SaTH over 20 years were examined by Senior Midwife, Donna Ockenden.

Recognising that the Government has invested “significantly” in supporting maternity services across the country, she thanked the Secretary of State for his ongoing support and called for the Department of Health and Social Care and NHS England and Improvement to commission a working group.

Independent of the Maternity Transformation Programme that has joint Royal College of Midwives and Royal College of Obstetricians and Gynaecologists leadership, Ockenden’s report recommended that the Government make plans to guide the Maternity Transformation Programme around implementation of Immediate and Essential Actions and the recommendations of other reports currently being prepared.

Chair of the review, Donna Ockenden said: “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next. For example, ineffective monitoring of fetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.

“The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved. There was a tendency of the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths.

“What is astounding is that for more than two decades these issues have not been challenged internally and the Trust was not held to account by external bodies. This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding.

“Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require.”

15 Immediate and Essential Actions:

  • Financing a safe maternity workforce
    • NHS England must commit to a multi-year investment plan to ensure the provision of a well-staffed workforce. Appropriate, minimum staffing levels must be agreed nationally, and locally, with these staffing levels adhered to.
  • Essential action on training
    • sufficient protected time must be allocated for training across all maternity specialisms including routine refresher courses as well as multidisciplinary team training, particularly in emergency drills.
  • Maintaining a clear escalation and mitigation policy when agreed staffing levels are not met
    • escalation should go to the senior management team, the Board, the patient safety champion and local maternity system (LMS). The Midwifery Continuity of Carer model must be suspended across all Trusts unless they can demonstrate staffing meets the minimum requirements. It should not be reinstated until robust evidence is available to support its reintroduction.
  • Essential roles for Trust Boards in oversight of their maternity services
    • Boards must work with their maternity departments to develop a process of regular reports and reviews to ensure improvement plans and actions take place. Every trust should have a patient safety specialist dedicated to maternity services.
  • Meaningful incident investigations with family and staff engagement and practice changes introduced in a timely manner
    • All investigation reports must use language that is easy for families to understand and lessons from clinical incidents must form the basis of a multidisciplinary training plan. A change in clinical practice must be evidenced by six months after an incident has occurred.
  • There must be mandatory joint learning across all care settings when a mother dies
    • a joint review panel must include representations from all clinical settings which were involved in the mother’s care. Post-mortem examinations must be conducted by expert pathologists in maternity and all learning must be introduced into clinical practice within six months of the investigation concluding. Investigations when a mother dies must be timely and treated as urgent and vital rather than families having to chase up trusts for conclusions as we have seen.
  • Care of mothers with complex and multiple pregnancies
    • Care must be provided by specialists who are familiar with managing complex pregnancies and multiple pregnancies. Where these specialisms are not found within a trust there must be early discussions with a nearby unit that has that expertise.
  • Ensuring the recommendations from the 2019 Neonatal Critical Care Review are introduced at pace
    • Maternity and neonatal services must continue to work towards a position of at least 85 per cent of births at less than 27 weeks gestation take place at a maternity unit with an onsite NICU and that appropriately trained consultants and staff are available 24/7.
  • Improving postnatal care for the unwell mother
    • All trusts must develop a system to ensure consultant review of all postnatal readmissions, and unwell 3 postnatal women, including those requiring care on a non-maternity ward and staffing levels must be appropriate in order to deliver this.
  • Care of bereaved families.
    • Bereavement services must be available every day of the week, not just Monday to Friday and staff must be trained to take post-mortem consent. All trusts need to ensure they have a system for follow-up appointments for families who have been bereaved.

“Deeply distressing”:

In a statement to the House of Commons, Health and Care Secretary, Sajid Javid told MPs in one case the hospital used post-it notes to pass on important clinical information, which were swept into the bin by cleaners.

In a statement, Chief Executive at SaTH, Louise Barnett said that the report was “deeply distressing” and that changes recommended by the Ockenden Report had already been introduced.

Barnett said “Today’s report is deeply distressing, and, on behalf of all at The Trust I offer our wholehearted apologies for the pain and distress that has been caused.

“We recognise the strength and determination shown by the women and families involved and take full responsibility for our failings as a Trust.

“This brings with it a duty to ensure that the care we provide today and in the future is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.

“We have had the first report from December 2020, which set out a wide range of actions for us, and other Trusts to deliver. Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden Report, and we are extremely grateful to Mrs Ockenden and her team for all they have done to help guide these essential improvements.

“We know that we still have much more to do to ensure we deliver the highest possible standard of care to the women and families we care for.

“Now that we have received the final report, we will approach the requirements with the focus and resolve we brought to the initial recommendations.

“We owe it to those families we failed, those we care for today and in the future, and our valued colleagues providing that care, to continue to make the necessary improvements so we are delivering the best possible care for the communities we serve.”

Staff morale at an all-time low:

The report has been published at a time when staff morale and retention have sunk to an all-time low. A poll of NHS staff across the UK last year by the charity Healthcare Workers’ Foundation found nearly three quarters have considered leaving in the last 12 months, while nearly 30 per cent also reported a strong likelihood of leaving the NHS in the next year. Nearly half said they would not recommend joining the health service.

Highlighting the severe impact of the pandemic on staffing across the NHS, Ockenden said “NHS staff, including maternity teams who have worked throughout this pandemic, are exhausted.” Calling for more funding, Ockenden endorsed the call by NHS Providers to expand spending on the maternity workforce to £200-£250m.

Final thought:

There is no doubt that this is one of the most distressing reports into the NHS this decade. Having read the full report each page is as shocking as the last.

The central question in Shropshire is how trust can be restored. With significant questions asked about the senior leadership team, there are calls for board members to be replaced as soon as possible.

Donna Ockenden presents her report and it’s findings

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