Urgent Action Needed to Improve Maternity Services Safety

Peter Russell

December 10, 2020

A first report into what has been described as the biggest maternity scandal in the history of the NHS called for urgent changes in all English hospitals to prevent more avoidable baby deaths, stillbirths, and neonatal brain damage.

The review into the care of mothers and babies who died at Shrewsbury and Telford NHS Hospital Trust (SaTH) said immediate action was needed by all hospital trusts in England to improve maternity safety.

The investigation, commissioned in 2017, and led by senior midwife Donna Ockenden, has identified 1862 cases, mostly between 2000 and 2019 for its investigation.

The interim report followed a review of 250 of the cases in which families had "shared with us their accounts of the overwhelming pain and sadness that never leaves them".

The Royal College of Obstetricians and Gynaecologists (RCOG) said the recommendations made "difficult reading" but should be acted on immediately.

Call for Urgent Action

The Ockenden report calls for 27 local actions for learning, and seven immediate and essential actions for all services.

Essential actions called for by the interim report are:

  • Strengthening safety in maternity units by increasing partnership between trusts and within local networks

  • Ensuring that maternity services listen to women and their families

  • Making sure that staff who work together, train together

  • Establishing robust pathways for managing women with complex pregnancies

  • Ensuring that women undergo risk assessments throughout their pregnancy

  • Establishing dedicated and experienced 'lead midwives' and 'lead obstetricians' to ensure best practice in foetal monitoring

  • Ensuring that women have accurate information to enable them to make informed choices about intended place and mode of birth

Presenting the findings, Ms Ockenden said many mothers and families had been left "utterly bereft", and their "suffering has been made worse as a result of the handling of these incidents" by SaTH.

She said: "For the last 3 years, families have told us they want to understand what happened to them; they want the Trust to learn from what has happened to them."

In July this year, West Mercia Police said they had launched an investigation into the care of mothers and babies at SaTH.

SaTH was rated 'inadequate' overall earlier this year by the Care Quality Commission.

Trust 'Would Implement All Actions'

In a statement today, Louise Barnett, chief executive at SaTH, apologised for "pain and distress" caused to mothers and families by its care and promised it would be "implementing all of the actions in this report" and that it could "assure the women and families who use our service that if they raise any concerns about their care they will be listened to and action will be taken".

Dr Edward Morris, president of the RCOG, said: "This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system.

"Reducing risk needs a holistic approach that targets the specific challenges of foetal monitoring interpretation and strengthens organisational functioning, culture and behaviour.

"All recent national reports have identified that staff struggle with a lack of resources and capacity to provide best care. Excellent services mean staff are empowered to work to the best of their abilities in a system that values and supports them, in order to provide the best possible care for women and their families.

"We owe it to all families affected by these tragedies to fully consider these recommendations, translate learning into practice and join up current programmes and resources within the maternity system to help the Government deliver on its manifesto promise to make the UK the best place in the world to give birth."

Nadine Dorries, minister for patient safety and maternity, said: "I expect the Trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies, and families.

"This Government is utterly committed to patient safety, eradicating avoidable harms, and making the NHS the safest place in the world to give birth.

"We will work closely with NHS England and Improvement, as well as Shrewsbury and Telford Hospital NHS Trust, to consider next steps."


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