The Largest Maternity Failing in NHS History – The Shrewsbury and Telford Hospital NHS Trust Inquiry
How it all started
Fought for by the parents of Baby Kate Stanton Davies and Baby Pippa Griffiths for many years, Donna Ockenden, a senior midwife and adviser, published the final report on the Inquiry into the maternity services at The Shrewsbury and Telford Hospital NHS Trust (‘the Trust’) today on Wednesday 30 March 2022.
Allowing families to be heard
Donna Ockenden wanted to ensure that the impact of death or serious health complications suffered by loved ones as a result of poor maternity care was properly investigated and that the families were provided with a voice.
The report places a spotlight on not only the concerns about the Shrewsbury and Telford Hospital NHS Trust but also on a number of recent reports of concerns in multiple other Trusts relating to the same issues.
Facts and figures from the report
The review investigated 1,592 clinical incidents and1,486 families were involved between 2000 and 2019 and included the following services: antenatal, intrapartum, postnatal, obstetric anaesthesia and neonatal care. This covered the period during pregnancy, delivery and the immediate period after the babies were born.
Sadly, in 12 cases of maternal death, it was concluded that none of the mothers had received care in line with what would be expected under best practice.
Where children were diagnosed with cerebral palsy, it was found that in 40% of cases there were significant or major concerns with the care received which might, or would have, resulted in a different outcome.
In cases of hypoxic-ischemic encephalopathy, where the brain does not receive enough oxygen or blood flow for a period of time, which often leads to disability, it was determined that in 65.9% of cases that the level of care provided to the newborn babies was of significant or major concern.
The review also looked at 498 cases of stillbirths and determined that 25% of these cases might or would have resulted in a different outcome had the mother and baby received the appropriate care.
Failings of the Trust
In the worst maternity failing in NHS history, it is important to understand exactly how this happened. The report is clear that there were repeated errors in patient's care which led to the injuries or deaths of either the mother or their babies.
Donna Ockenden describes an overarching theme that the Trust would fail to investigate and learn from the multiple serious critical incidents that occurred. Parents were not heard and there was a lack of transparencies and openness in relation to their complaints. Many parents felt as though their situations were ‘pushed under the carpet’ or covered up.
There were significant or multiple delays in women being admitted to labour, being assessed for emergency intervention, or being reviewed by consultants. When involving the obstetric anaesthetists, this often happened at the very last minute and meant that the anaesthetist was unable to assess patients correctly.
Many women were also discharged inappropriately and were later readmitted after becoming extremely unwell to have emergency procedures. The Trust were reluctant to refer mothers or babies to any specialists as they were seen to be ‘overly confident’ in their ability to manage complex pregnancies. This was evident in the neonatal unit which operated beyond its designated scope.
There was a culture of fear in the Trust between the midwifery and obstetric staff which led to a lack of escalation when a patient needed it. The culture created a lack of compassion for patients, unsafe clinical practices which were left unchallenged and unaddressed, and each time, investigatory processes were not followed which led to serious incidents not being reviewed or learnt from.
Outcome of the report
The final report has set immediate and essential actions for additional funding for maternity services across the nation. The report highlights the importance for continuity of care, so that women receive safe and personalised care from the same midwifery team, with a named midwife who takes responsibility for ensuring the needs of the woman and her baby are met through all stages. This however has been suspended until the staffing levels of the NHS are improved.
The Shrewsbury and Telford Hospital NHS Trust must make immediate and significant improvements. Incidents must be graded appropriately and recorded. All investigations must take place by a multi-professional team and lessons must be learnt to ensure the safety of patients.
The safety and quality of maternity services is paramount to ensure families across England are provided with the best level of care now and in the future.
If you have been impacted by any of the topics above, please do get in touch with our clinical negligence team who may be able to assist you. We have a specialist team who deal with stillbirth and neonatal deaths as well as catastrophic injuries caused by negligence during the antenatal, or intrapartum, or neonatal period.
The full report can be found here.