The final report conducted by senior midwife Donna Ockenden was published this week, with findings from her independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust. Building on the first report published in December 2020, the review was painstakingly thorough and gave voice to some 1500 families dealing with their experiences of the maternity services at this NHS Trust between 2000 and 2019. The numerous failings highlighted in the report have resulted in a huge number of poor outcomes, including stillbirths, neonatal deaths, maternal deaths and children left with severe brain injury.
The review highlights a series of failings by Shrewsbury and Telford Hospital NHS Trust in the following 2 key areas:
- Patterns of repeated poor care
- Failure in governance and leadership
Specific failures highlighted in the review include:
- A reluctance to undertake caesarean sections
- Inadequate monitoring of fetal growth
- Overconfident maternity staff and understaffing/lack of training
- Ignoring family concerns and making them feel they were at fault
- A culture that did not allow maternity staff to voice concerns
The above list only touches the surface of the failures outlined in the report. Commentators have referred to this report as a ‘watershed’ moment and it has, quite rightly, attracted wide media interest.
Whilst this report is a culmination of the feedback from all the affected families and in particular the 2 families at the centre of the report, without whose determination and relentless pursuit of justice the review would not have happened, we have to ask ourselves why is it so hard for the NHS to learn from past failings. This report is not the first of its kind and will, sadly, not be the last review of maternity services in the NHS.
It is true that lessons have been learned and improvements made over the years with periodic injection of funds into maternity services, but time and again the same themes emerge with devastating consequences for the families and also the staff concerned.
We are proud of our NHS service which does an amazing job under extraordinary pressure, but when the stakes are so high, how can we be sure that the right support is in place for the right services at the right time?
We welcome this report and hope that, by putting the families centre stage and at the heart of this report, the NHS finds a new way to take a careful look at what needs to change and make those changes in a meaningful way. Only then can families feel reassured, confident and proud of our NHS maternity services. We do not want to be here again.
We continue to see families who have suffered the impact of similar failures. Often they are driven by the desire to ensure other people do not have to go through the same experience; sometimes they are simply seeking a proper explanation or apology. Our team at Moore Barlow includes solicitors who have worked within the NHS as doctors and complaint investigators. We have very wide experience of resolving claims arising from sub-standard midwifery, obstetric and neonatal care. We believe that specialist lawyers have an important role to play in improving patient safety.