The Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust (“the Trust”) began in the summer of 2017 and was originally requested by the Rt Hon Jeremy Hunt, MP, the then Secretary of State for Health and Social Care, and commissioned by NHS Improvement (NHSI), to examine 23 cases of concern collated by the tireless efforts of the parents of Kate Stanton-Davies and Pippa Griffiths, who both died after birth at the Trust in 2009 and 2016 respectively.
The review, led by senior midwife Donna Ockenden, follows a five-year investigation into the maternity care at Shrewsbury and Telford Hospital NHS Trust (SaTH).
The Ockenden Report: Kim Huggins Speaks to Libby Purves on Times Radio Breakfast Show
An independent and multi-professional team of 90 midwives and doctors reviewed the maternity care of 1,486 families between 2000-2019. Unprecedented in terms of size and scale, it is the largest inquiry into a single service in the history of the NHS.
The initial review was first launched back in 2017 and an interim report was published in December 2020, looking at the first 250 cases with the second report published on 30.03.2022, sadly identifying that not much had changed since the initial investigation began.
The hope is that the report will provide an opportunity to immediately improve the safety and quality of maternity service provision for families at the Trust and across England.
Table 1 outlines the number of families and clinical incidents throughout the review period.
What Went Wrong?
Section 3 of the report looks into the thousands of cases and provides an insight into the mistakes made. Some mistakes involved:
- Foetal growth, abnormalities and management.
- Management and safety in multiple births.
- Inconsistent or absent Obstetric reviews on wards.
- Failure to escalate/act upon risk and transfer appropriately.
- Failure to properly monitor on the labour ward.
- Reluctance to escalate concerns regarding care and treatment to obstetric and neonatal colleagues.
- High risk and complex cases not being escalated in a timely manner.
- Failing to recognise sick or deteriorating women.
- Delays in acting upon abnormal CTG leading to poor foetal outcome.
- Leadership and culture on the ward was poor resulting in a lack of protocol, documentation and direction.
- Poor staffing levels in midwifery and obstetrics affecting the ante, peri and post natal care
- Reliance upon locum medical workforce working at middle grade at the Trust without evidence of documented supervision and governance.
- Inadequate consultant involvement in the management of complex postnatal problems.
- Limited involvement of anaesthetic input.
- Failure to provide anaesthetists the opportunity to make a considered assessment of the patient and to take steps to optimise the patient’s condition prior to anaesthesia.
- Common obstetric conditions were not recognised or not managed in line with established guidelines
- Failure to listen
- Newborn Life Support algorithm was not followed in the correct order.
- Prolonged hypoglycaemia without effective or timely intervention.
Case examples:
“In 2002 a woman with pre-eclampsia discharged herself 36 hours after delivering 25 week stillborn twins as she felt her care ‘was appalling’. (2002)”
“In 2002 a family complained about the way that a midwife sonographer informed them that one of the twins had died when the mother presented with ruptured membranes at 37 weeks gestation. (2002)”
“In a surprisingly large proportion of the cases reviewed for this report, there is evidence of women receiving excessive volumes of intravenous fluid prescribed by both anaesthetists and obstetricians. This took place in the presence of severe pre-eclampsia, contrary to local and national guidance regarding fluid restriction in such circumstances, and also after post-partum haemorrhage. In some cases, the women were displaying clear signs and symptoms of fluid overload over a protracted period before it was noted by medical staff.”
“A woman who had symptoms and signs of severe pre-eclampsia in 2008 had her baby delivered by caesarean section after failed induction of labour. She was diagnosed with left ventricular failure and pulmonary oedema in the postoperative period when she had a positive fluid balance in excess of 2000mls. Fluid administration was consistently in excess of the nationally advised limit of 80ml/h with 1500ml being given in theatre alone. A handwritten note in the patient’s hospital records stated that her case had been discussed at a governance meeting, but no documents reflecting this were supplied to the review team by the Trust. (2008)”
“In 2007, a growth restricted term baby had very low cord pH at birth (but the baby quickly recovered with Apgar226 scores of 8 and 10), and required only facial oxygen. A paediatrician appropriately requested to keep baby warm and establish feeds. On review at 30 minutes, they noted profound hypoglycaemia. The paediatrician instructed “commence feeds as soon as mum ready and if concerned to inform NNU”. A doctor was called to review the baby when it was noted to be dusky aged 1 hour. The requested senior review said baby did not need admission. No further glucose levels documented until admitted at 13 hours, when they were normal. This baby was later diagnosed with HIE. (2007)”
The shocking statistics
The report revealed:
- 201 babies could have survived with better care, (this related to 70 neonatal deaths and 131 cases where babies were stillborn).
- 84 cases of brain damage: 29 cases where babies suffered severe brain injuries and 65 incidents of cerebral palsy.
- Between 2011 and 2019, 40% of stillbirths and 43% of neonatal deaths did not even have an investigation.
- Of 12 maternal deaths, none of the mothers had received care in line with best practice and in three-quarters of all cases the care could have been significantly improved.
- Only one maternal death investigation was conducted by external clinicians, whilst internal reviews were rated as poor, failing to recognise system and service-wide failings and failing to follow appropriate procedures and guidance.
- Of 498 cases of stillbirth, one in four were found to have significant or major concerns in maternity care which if managed appropriately might, or would have, resulted in a different outcome.
- There were significant and major concerns in the care provided to the mother in two thirds (65.9 per cent) of all Hypoxic ischaemic encephalopathy (oxygen deprivation) cases.
- Most of the neonatal deaths occurred in the first 7 days of life. Nearly a third of all incidents reviewed (27.9 per cent) were identified to have significant or major concerns in the maternity care provided which might or would have resulted in a different outcome.
Key Findings
- Not all mistakes in maternity care were being investigated by internal and external review bodies
- Investigations were not carried out to a high standard and incidents were downgraded to avoid scrutiny
- There was a reluctance to perform caesarean sections which contributed to many babies dying during birth or shortly afterwards
- Parents’ concerns were being ignored and “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths”
- Culture of bullying and fear amongst the staff within the Trust which included a reluctance to acknowledge and escalate concerns
- Staff shortages affected care; lack of consultant presence on wards and on rounds and in the management of complex postnatal cases
- Parents felt that staff lacked empathy; “discussion with families about having a post-mortem examination was insensitive or unhelpful”
- Lack of on-going training or learning from mistakes
- Repeatedly failed to correctly monitor baby’s heart rates, despite concerns
- Poor management of common obstetric conditions such as pre-eclampsia
- Mistakes made in the techniques for resuscitation and stabilisation at birth
Louise Barnett, Chief Executive at the Shrewsbury and Telford Hospital NHS Trust said: “Today’s report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust……We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart…… we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve.”
Recommendations
The Ockenden report made a total of 84 recommendations: – 66 for the Trust, 15 for “immediate and essential action” to improve care and safety in maternity services across England and 3 for Sajid Javid, The Health Secretary.
When asked about accountability Mr Javid said:
“a number of people who were working at the trust at the time of the incidents have been suspended or struck off from the professional register and members of senior management have also been removed from their posts”. In addition, ‘Operation Lincoln’ is an is an active police investigation looking at nearly 600 cases.
Donna Ockenden’s 4 key pillars to drive maternity services forward:
- Safe staffing which is fully funded
- Well trained staff
- Learning from mistakes
- Listening to families
But this can only be achieved with full funding in the region of around £200 million, full commitment, honesty, transparency and accountability. Until then, the safety of maternity services in the UK remains questionable.
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