Review into maternity care at NHS trust paints ‘harrowing’ picture

The final report of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust has been published, painting a ‘tragic and harrowing’ picture of repeated failures in care over two decades.

The review into almost 1,600 clinical incidents identified failures to listen to families, failure to learn from clinical incidents and failure of multiple external bodies to act in improving maternity services at the Trust over two decades.

The Ockenden review team spoke to the families involved about their care and examined medical records, as well as collecting survey responses and confidential interviews with current and former staff.

The report identified hundreds of cases where the Trust failed to undertake serious incident investigations, with even cases of death not being examined appropriately. Where investigations did take place, they did not meet the expected standards at that time and failed to identify areas for improvement in care.

These combined failings led to missed opportunities to learn, with families experiencing repeated serious incidents and harm throughout the period of the review.

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.’

Health and Social Care Secretary Sajid Javid commented: ‘Donna Ockenden’s report paints a tragic and harrowing picture of repeated failures in care over two decades, and I am deeply sorry to all the families who have suffered so greatly.

‘Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.

‘I would like to thank Donna Ockenden and her whole team for their work throughout this long and distressing inquiry, as well as all the families who came forward to tell their stories.’

Photo by Heather Mount