Review calls for urgent changes into maternity services at The Shrewsbury and Telford Hospital NHS Trust

The Ockenden review into maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned back in 2017 by the then Secretary of State for Health and Social Care, Jeremy Hunt MP.

The inquiry into deaths and allegations of poor care at the Shrewsbury and Telford Hospital NHS Trust originally focused on 23 cases, but since the original launch of the review many more families came forward with concerns about their care and now the review is examining the cases of 1,862 families.

The review calls for 27 local actions for learning and seven immediate and essential actions for all maternity services to be implemented.

Today’s report is published following the clinical reviews of 250 of the family cases.

The independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust is led by midwifery expert Donna Ockenden and has uncovered 1,862 serious incidents including hundreds of baby deaths and an unusually high number of maternal deaths, mostly between 2000 and 2019.

The report says that families have repeatedly told of two key wishes. Firstly, they want questions answered in order that they understand what happened during their maternity care. Secondly, they want the system to learn, so as to ensure that any identified failings from their care are not repeated at the Trust or occur at any other maternity service in England.

Publishing her report, Donna Ockenden said: "I would like to express my very sincere thanks to the families who are at the very centre of this maternity review.

"This must include the very many families who tried to raise serious concerns about maternity care at the Trust who have told us they were not listened to.

"We have been listening so that we can enable the trust and wider maternity services across England to be clear about the improvements needed. This will ensure that maternity services are enabled to continuously improve the safety of the care they provide to women and families."

Essential Actions

The review concluded there are seven immediate and essential actions for maternity services across England.

Enhanced Safety - Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks.

Neighbouring Trusts must work collaboratively to ensure that local investigations into Serious Incidents (SIs) have regional and Local Maternity System (LMS) oversight.

Listening to Women and Families - Maternity services must ensure that women and their families are listened to with their voices heard.

Staff training and working together - Staff who work together must train together.

Managing complex pregnancy - There must be robust pathways in place for managing women with complex pregnancies

Through the development of links with the tertiary level Maternal Medicine Centre there must be agreement reached on the criteria for those cases to be discussed and /or referred to a maternal medicine specialist centre.

Risk assessment throughout pregnancy - Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway.

Monitoring  fetal wellbeing - All maternity services must appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion best practice in fetal monitoring.

Informed Consent  - All Trusts must ensure women have ready access to accurateinformation to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.

Report Origins

This first report owes its origins to Kate Stanton Davies and her parents Rhiannon Davies and Richard Stanton and to Pippa Griffiths and her parents Kayleigh and Colin Griffiths. Kate’s death in 2009 and Pippa’s death in 2016 were avoidable. 

In a void described by the families as ‘incomprehensible pain’, they undertook their own investigations to highlight the deaths of their newborn daughters, and persisted in their call for an independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust; through their tenacity and efforts a review was instigated.

Trust Response

Louise Barnett, Chief Executive at The Shrewsbury and Telford Hospital NHS Trust, said:

“I would like to thank Donna Ockenden for this report but more importantly the families for coming forward.

“As the Chief Executive now and on behalf of the whole Trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our Trust.

“We commit to implementing all of the actions in this report and I can 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.”

“If you are pregnant and have any questions about your current care, please contact your midwife.”

Government Response

Responding to the report, patient safety and maternity minister Nadine Dorries said in a statement: “My heartfelt sympathies are with every family who has been affected by the shocking failings in Shrewsbury and Telford Hospital NHS Trust’s maternity services.

“I would like to thank Donna Ockenden and her team for their hard work in producing this first report and making these vital recommendations so lessons can be learnt as soon as possible.

"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.”

Full Findings

The full findings will be made public sometime next year, West Mercia Police is also carrying out an investigation.