Donna Ockenden: ‘The Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust’

Wednesday 30 March 2022 marks the publication of Donna Ockenden’s final independent review into maternity services at The Shrewsbury and Telford Hospital NHS Trust. The long-awaited report follows on from the first report, ‘Emerging Findings and Recommendations from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust’ which was published in December 2020. 

The first report observed important emerging themes that concerns were not appropriately escalated, leading to a direct impact on the safety and quality of care provided to women and their babies. The aim of the first report was to focus on immediate improvements for the Trust and the wider maternity system across England. 

The final report which was published today has reviewed the maternity care received by 1,486 different families, involving 1,592 clinical incidents. Cases span from as early as 1973, with the latest in 2020. As such, it is the largest ever number of clinical reviews conducted as part of an inquiry relating to a single service in the history of the NHS. 

The report highlights woefully poor practice over a period of decades, to include a reluctance to carry out caesarean sections, a failure to train staff properly to read CTG (heart monitoring) traces; inadequate team working, a refusal to follow national guidelines, an inability to learn from mistakes and a culture of cover-up. It has been identified that there are 60 areas where improvements could be made at The Shrewsbury and Telford Hospital NHS Trust.

Harrowingly, the report identifies 201 cases of still birth and neonatal deaths that could have been avoided if better care had been provided and 9 avoidable maternal deaths. Other babies were starved of oxygen and left with life-changing disabilities. It was found that false reassurances were given to families about the maternity services despite repeated concerns being raised. 

Within the report, Donna Ockenden addresses the Secretary of State for Health and Social Care and states that the review is about an NHS maternity service that failed – “it failed to investigate, failed to learn and failed to improve and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives”. 

Whilst the report says the review team are encouraged by staff feedback that following the publication of the first report in December 2020 there does seem to have been a recent improvement in maternity services at the Trust, even now early in 2022 there remains concern that NHS maternity services are still failing to adequately address and learn lessons from serious maternity events.

Commenting on today’s publication, the Birth Trauma Association’s CEO, Dr Kim Thomas, said: 

“The Ockenden’s findings are so shocking that they must provide an impetus for change. The lives of babies and mothers have been lost as a result of neglectful care over a period of decades. The fact that it has taken this long to investigate is in itself highly worrying. It is now time for an overhaul of maternity care that priorities the safety and wellbeing of mothers and babies”. 

We have profound sympathy for all of the families who have suffered indescribable loss and harm as a result of maternity failings at The Shrewsbury and Telford Hospital NHS Trust and we hope that this report will herald the improvements in maternity care that they have been asking for.