Failings in Maternity Care Confirmed by Donna Ockenden Report

This year we have united in pride and admiration for our NHS but today’s report reminds us that we must also accept that in the past not everyone has experienced the standard of care from the NHS that they deserve.

Today’s report from Donna Ockenden highlights shocking examples of failings in maternity care provided at the Shrewsbury and Telford Hospital NHS Trust between 2000 and 2019. The report identifies disappointing and deeply worrying themes, which have jeopardised patient safety and caused harm to babies and mothers for years.

Women at their most vulnerable were not listened to and were denied empathy, appropriate care and the opportunity to deliver their babies safely. A full list of the failings can be found within the report linked here, but the most harrowing findings include:

  • The failure to appropriately risk assess pregnancies. There was little or no discussion with the mothers about options for delivery and the risks involved. Where a mother was to give birth was decided for her, without full disclosure of the risks and options available.

  • There were a significant number of cases where midwives and obstetricians did not demonstrate an appropriate level of competence in particular in relation to knowing when to escalate, the interpretation of foetal wellbeing traces and the use of oxytocin.

  • There is disturbing evidence of a number of repeated attempts at vaginal delivery with forceps, sometimes with excessive force causing significant injury and death.

  • The Trust perceived their low caesarean rates as “good care” when, in reality, this created a dangerous culture where women had little freedom to express any choice on mode of delivery. In some individual cases the report recognises that earlier recourse to a caesarean delivery would have avoided death and injury.

What happens next?

As we at Lanyon Bowdler fight for justice for those families who have been affected, we must also look to the future. This is our local trust. Our staff, friends and family all give birth here and so this is an incredibly personal cause to our team.

Alongside specific recommendations for Shrewsbury and Telford Hospital NHS Trust, the report has identified the following seven essential actions, which must be implemented immediately, across nationwide maternity services:

  • Enhance and strengthen safety by increasing partnerships between trusts and local networks.

  • Ensure women and families are heard.

  • Staff who work together must train together.

  • There must be robust pathways in place for managing women with complex pregnancies.

  • Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway.

  • All maternity services must appoint a dedicated lead midwife and lead obstetrician both with demonstrated expertise to focus on and champion best practice in foetal monitoring.

  • All trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.

The second part of Ms Ockenden’s report will follow in 2021, however it is expected that the Trust acts upon her recommendations immediately. Improvements must be made to ensure the maternity services at our local trust are safe.

We have profound sympathy for our clients and the families that have suffered indescribable loss. If you would like to discuss a potential claim, please contact us on 0800 294 5915 or via our website for a free consultation.