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The Nottingham Maternity Unit was rated as inadequate by the Care Quality Commission (CQC) in 2020 and a review, similar to that completed by Donna Ockenden into the Shrewsbury and Telford Hospital Trust (SaTH), began. The review relates directly to the Nottingham University Hospital (NUH) Trust after repeated examples of poor care were uncovered along with failures to investigate.

The CQC issued a warning notice in March 2022 highlighting specific concerns over triage services and increased stillbirths. Nineteen serious incidents were reported by maternity staff between March 2021 and February 2022, as well as five current Healthcare Safety Investigation Branch investigations. The CQC warning was issued having identified that staff were not always carrying out observations to make sure patients’ conditions were not deteriorating, and that triage wait times were too long.

Families involved in the review previously sought the input of Donna Ockenden in the Nottingham review due to a lack of confidence in the clinical team involved, the extremely slow pace of the review and the increasing numbers of families coming forward. The original remit was too narrow and considered not independent enough.

An interim report was published in April 2022, which highlighted that maternity services nationally were ‘under immense scrutiny’, in light of reports such as that conducted by Ockenden into SaTH. Evidence of ‘bullying behaviour’ had been uncovered with some staff displaying ‘unacceptable behaviours such as being rude and abrasive’. Sharon Wallis, director of the midwifery unit at NUH said “our teams are working hard to make the necessary improvements, but recognise we have more to do and are absolutely determined to speed up the pace of change and deliver quality services”.

NHS England have now confirmed that Donna Ockenden will chair a new team with new terms of reference into the review of the maternity services at NUH. Sir David Sloman, Chief Operating Officer for NHS England has said he has “taken on board various views” those concerned with the original review team have shared. Ockenden will develop terms, which reflect both the need to drive urgent improvements to local maternity care and the need to deliver actionable recommendations, which can be implemented as quickly as possible. No timescale has yet been confirmed however.

This announcement is no doubt welcomed by those families involved and will hopefully result in a robust review. This change in leadership comes as a result of the families campaigning for Donna Ockenden’s involvement, and some even publishing personal details of their cases online in a desperate bid to be heard by those in charge.

Donna Ockenden taking over as chair of the review offers hope that the failings at NUH, specifically the maternity unit, will be uncovered and hopefully encourage ongoing and future care to be improved. She has commented that her first priority is to listen to those families affected and notes that the CQC safety warning, and the stories shared already, indicates ‘something that is very, very wrong at the trust’.

Lanyon Bowdler are supporting hundreds of families under Donna Ockenden’s review into the maternity care at SaTH. If you or your family have been affected by poor maternity care either under SaTH or Nottingham, please speak to a member of our specialist team.

We are all taught from a very young age that if it’s a genuine emergency, where someone is seriously injured or ill, and their life is at risk, we should call 999 and the ambulance service will be there to help. However, West Midlands Ambulance Service (WMAS) is now at terrible risk of collapse.

WMAS Director, Mark Docherty, has warned that by 17 August 2022, the service will fail. They are currently facing a ‘catastrophic situation’ of long hospital handovers and delayed response times which is undoubtedly putting lives at risk. Mr Docherty has warned that patients are dying needlessly everyday due to the strain on the service.

In an interview with the Health Service Journal, Mr Docherty raised his concerns over the potential ‘Titanic moment’ collapse of WMAS and called for NHS England and the Care Quality Commission (CQC) to step in and control the concerning situation.

A major concern is the that some patients have waited in the back of an ambulance for 24 hours before being admitted to hospital, and that serious incidents have quadrupled in the past year - largely as a result of these severe handover delays. This is a national problem and NHS data has shown that in March 2022, ambulance trusts nationwide had slow response times to even the most urgent of incidents.

Mr Docherty says the NHS England officials have downplayed the problem of delayed discharge, and he has questioned why the CQC have issued improvement notices about hospital corridor care, but not the ambulance handover delays when patients are dying every day due to avoidable delays. The CQC have commented that the impact of the escalating pressure on the NHS is severe and the long delays for patients are unacceptable.

Over 100 serious incidents have been recorded at the West Midlands Ambulance Service relating to patient deaths, resulting from the service being unable to respond as the ambulances were held outside hospitals. There have been a number of reports of Shropshire patients waiting extreme periods of time for hospital beds, and repeated anger over death’s occurring as a result of the ambulance delays.

Mr Doherty predicts that WMAS will collapse by 17 August 2022, stating this is when a third of the resources will be lost to delays - meaning that ambulances simply will not be able to respond to emergency calls. The risk level was rated at its highest level ever in October 2021, and the situation has failed to improve since. In April 2022, there were 17,795 hours lost due to handover delays of over 30 minutes. By June, this had risen to over 2,100 hours which is the highest number ever experienced by WMAS, with the worst delay involving a crew waiting more than 25 hours at the Royal Shrewsbury Hospital.

NHS England has said £150 million has been allocated to tackling this issue, but is this just a tiny sticking plaster on a massive gaping wound? Is it too late for the service to be saved? Will other ambulance services nationwide face the same fate?

With Mr Docherty stating that this is the biggest problem facing the NHS right now, the question remains: how much worse can it get and what happens if this collapse does in fact happen?

Shrewsbury and Telford NHS Trust (SaTH) have been fined over one million pounds after admitting failures in medical care that contributed to the deaths of two patients.

SaTH were prosecuted by the Care Quality Commission (CQC) under the Health and Social Care Act 2008. Appearing before Telford Magistrates, SaTH admitted three charges of failing to provide treatment and care in a safe way, resulting in harm.

In the first case, Mohammed Zaman, 31, died of severe blood loss while undergoing dialysis at the Royal Shrewsbury Hospital in 2019. A catheter came out of his jugular vein which set off an alarm. However, he was not checked before staff switched it off, and by the time staff had noticed what had happened, he had lost half of his supply of blood. SaTH admitted failings and were fined £800,000.00.

In the second case, Max Dingle, 83, was placed on a larger bariatric bed which staff were not trained on how to use correctly. He suffered a cardiac arrest after his head became trapped between a mattress and the bed rail, and sadly could not be resuscitated.

Prosecuting, the CQC said both patients and their families had been "severely let down" by SaTH. "People using health and social care services have the right to safe care and treatment, so it's unacceptable that patient safety was not well managed by Shrewsbury and Telford Hospital NHS Trust," Fiona Allinson, from Watchdog, said.

Following the hearing, SaTH issued a statement in which its director of nursing Hayley Flavell said: "We are truly sorry for the pain and distress caused as a result of the failures in the provision of care. We offer our sincere apologies and heartfelt condolences to the families we let down".

Sadly, this is not the first time SaTH have caused or contributed to avoidable deaths. In March, a damning review into the maternity services at SaTH was released by Donna Ockenden which found "repeated errors in care" at the Trust contributed to the deaths of 201 babies between 2000-2019.

West Mercia Police are presently carrying out Operation Lincoln - an investigation into the care of mothers and babies who died or suffered serious harm under maternity services at SaTH between 1 October 2003 and the present day.

Lanyon Bowdler are assisting a large number of families who are part of Operation Lincoln and the Donna Ockenden review, therefore if you require any assistance or if you need advice, please contact us.