Damning report reveals scale of maternity failures at The Shrewsbury and Telford Hospital NHS Trust

The long-awaited Ockenden review was published at 10am and details of the shocking report were given by Donna Ockenden, the senior midwife who chaired the review into the maternity services at The Shrewsbury and Telford Hospital NHS Trust. She spoke from a hotel in Shrewsbury, attended by some of the brave families who have spoken up.

The review, which can be read in full here, records woefully poor practice over a period of decades. This included an obsession with avoiding caesareans that put mothers’ and babies’ lives in danger; a failure to train staff properly to read CTG (heart monitoring) traces; inadequate team working; a refusal to follow national guidelines; an inability to learn from mistakes; and a culture of cover-up.

The review found that some 201 babies and nine mothers might have survived if they had received better maternity care. It examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents where medical records and family consent was gained. 

The Ockenden review team spoke to the families involved about their care and examined medical records. In addition, current and former members of staff completed surveys, were interviewed and contacted the review team to talk confidentially.

The review team also scrutinised vast volumes of documentation provided by the Trust. The review found repeated failures in the quality of care and governance at the Trust throughout the last two decades, as well as failures from external bodies to effectively monitor the care provided.

Hundreds of cases where the Trust failed

The final report identifies hundreds of cases where the Trust failed to undertake serious incident investigations, with even cases of death not being examined appropriately. The review found that where investigations did take place they did not meet the expected standards at that time and failed to identify areas for improvement in care. 

Many more suffered devastating injuries. The reluctance to carry out caesarean sections led to women receiving high doses of artificial oxytocin to speed up contractions, as well as a reliance on forceps that led to fractured skulls and broken bones. Other babies were starved of oxygen and left with life-changing disabilities. Instead of learning from these incidents, the trust decided to minimise them, abdicate responsibility and cover them up.

Chair of the review Donna Ockenden, said: “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next. For example, ineffective monitoring of fetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.

“The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved. There was a tendency at the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths.

“What is astounding is that for more than two decades these issues have not been challenged internally and the Trust was not held to account by external bodies. This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding.

“Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require.”

Investment, recruitment and retention

In addition, the review also calls for NHS England to invest in a recruitment and retention drive to alleviate pressures in understaffed maternity services, more investment in training for midwives, support staff and doctors, as well as actions to ensure midwives and their medical colleagues want to remain working in the NHS.

Donna added: “A death of a mother or baby, or a birth incident which results in an injury should never be ignored. Thorough and timely expert investigations have to be undertaken which result in meaningful actions that improve quality of care, diagnosis and processes going forward.

“There should never again be a review of this scale, in both numbers, and the length of years across which these concerns remained hidden. I pay tribute to all the families that have been involved in this review and thank them for working with me and my team. I would also like to extend my heartfelt thanks to my independent review team, the majority of whom have worked with me alongside their own clinical responsibilities. Families and your colleagues across the NHS tell me every day, how grateful they are for your efforts and I would like to recognise your dedication today.

“The legacy of this review should be a maternity service across England that is appropriately funded, well-staffed, trained, motivated and compassionate and willing to learn from failings in care.”

Staff still fearful of speaking up at Trust

Concerns have been raised in the report that staff are still not being listened to about their concerns at the maternity wards despite its failings.

Ockenden said: “We are very concerned but in very recent weeks staff currently working at the trust have contacted the review team to express their concerns about maternity services at the trust in the here and now.

“Staff have described to us that they were frightened to speak to the maternity review team and were advised by trust managers not to participate in the staff voices initiative.

“One staff member said to us, and this is a message for the families, I am sorry and I know that sorry is not enough, but by engaging with this review we hope that our voices will finally be acknowledged and that change will happen so that there are robust and independent places for clinicians to speak out that acknowledge what we're saying, what needs changing and that we act on this without fearing reprisals.

“Another said very recently, I mean March 2022, if I could say anything to the families it would be that there were people who tried to make changes, we tried to escalate our concerns and be heard but every process we used was set up not to acknowledge, our voices or the problems we were highlighting, we were ignored and made out to be the problem - but ultimately we failed to make ourselves heard.”

Page 184 of the report quotes what staff have said in recent weeks and was only added to the report in the final days before publication.

Ockenden said this morning: “A current staff member in maternity services at the trust spoke to the review team in early 2022 but described themselves as fearful to do so. The staff member said: I really had to think very carefully about approaching the staff voices, that's us, when we were told not to speak out - but I will do it and take the consequences because it is the right thing to do.”

Trust responds to report

Responding to the publication of the final report of the Independent Review of Maternity Services – the ‘Ockenden Report’ – Louise Barnett, Chief Executive at The Shrewsbury and Telford Hospital NHS Trust said:

“Today’s report is deeply distressing, and, on behalf of all at The Trust I offer our wholehearted apologies for the pain and distress that has been caused.

“We recognise the strength and determination shown by the women and families involved and take full responsibility for our failings as a Trust.

“This brings with it a duty to ensure that the care we provide today and in the future is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.

“We have had the first report from December 2020, which set out a wide range of actions for us, and other Trusts to deliver. Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden Report, and we are extremely grateful to Mrs Ockenden and her team for all they have done to help guide these essential improvements.

“We know that we still have much more to do to ensure we deliver the highest possible standard of care to the women and families we care for.

“Now that we have received the final report, we will approach the requirements with the focus and resolve we brought to the initial recommendations.

“We owe it to those families we failed, those we care for today and in the future, and our valued colleagues providing that care, to continue to make the necessary improvements so we are delivering the best possible care for the communities we serve.”

Deeply sorry

Commenting on the report, Health and Social Care Secretary Sajid Javid said: "I am deeply sorry to all the families who have suffered so greatly.

"Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.

"I would like to thank Donna Ockenden and her whole team for their work throughout this long and distressing inquiry, as well as all the families who came forward to tell their stories."

Criminal investigation

West Mercia Police says it is engaging with the Crown Prosecution Service as part of its investigation into maternity care at The Shrewsbury and Telford NHS Hospital Trust.

Detective Chief Superintendent Damian Barratt, who is leading the investigation, said: "We have been liaising closely with the Ockenden Review and are, of course, aware of the release of the report today.

“Our investigation, named Operation Lincoln, was launched in 2017 to explore whether there is evidence to support a criminal case against the Trust or any individuals involved. This investigation remains ongoing and very much active.

“This is a highly complex and very sensitive investigation that has required us to speak to a large number of people to gather as much information as we can. We are also consulting with a number of medical specialists to ensure our investigation is thorough and that the best possible investigation is completed for the families involved.

“No arrests have been made and no charges have been brought, however we are engaging with the Crown Prosecution Service (CPS) as our enquiries continue. We will be fully reviewing the findings of the report and feeding appropriate elements into our investigation.

“We do not underestimate the impact the report’s findings and our ongoing investigation has on the families involved, who have suffered unimaginable trauma and grief that they still live with today. Our thoughts remain with them, and we can reassure the community that when there is an update on our investigation we will share this with the families involved first and foremost and then to the wider public."

Families still searching for answer

Beth Heath, head of clinical negligence at Lanyon Bowdler Solicitors, is assisting dozens of families with legal cases against the Trust, and said the report made for distressing reading.

“We wholeheartedly support the recommendations of the report and, on behalf of the many families we have assisted with claims of clinical negligence, can only hope this represents a turning point for maternity services at Shrewsbury and Telford hospitals,” she said.

“Unfortunately, there are still unanswered questions for a lot of families. The Ockenden Review looked at cases involving 1,486 families and 1,592 cases where there were alleged failings in maternity care, limited to the period between 1999 and 2019 - and there are numerous cases outside the review

“The main aim of clinical negligence claims is to get answers to those questions about what went wrong. The most important thing for families who have been affected by poor standards of care is always to see that lessons have been learnt and meaningful change has led to real improvements.”

Beth added: “Following the interim report published by Donna Ockenden in December 2020, several urgent recommendations were made and there is concern that these recommendations are not being met.

“We are still seeing cases with the same issues arising.

“People need to be confident that standards are being raised in their local hospitals, and I hope this report will not be ignored, and that its recommendations will be acted upon urgently to improve the level of maternity services for patients and the medical staff.”

Time for an overhaul of maternity care

Commenting on today’s publication, the Birth Trauma Association’s CEO, Dr Kim Thomas, said:

“In 2015, a highly critical review into failings of maternity care at Morecambe Bay was published. We hoped then that things would change for the better. Sadly, this has proved not to be the case. Ockenden’s findings, however, are so shocking that they must provide an impetus for change. The lives of babies and mothers have been lost as a result of neglectful care over a period of decades. The fact that it has taken this long to investigate is in itself highly worrying.

“It is now time for an overhaul of maternity care that priorities the safety and wellbeing of mothers and babies. That overhaul should include making sure that maternity units adhere to guidelines and best practice; that team-working and collaboration between obstetricians and midwives is encouraged; that a culture of learning replaces a culture of cover-up; that midwives’ training is kept up-to-date; and finally, that caesarean targets are abandoned altogether and maternity units’ performance is measured on outcomes, not processes. Those outcomes should, above all, include a healthy mother and baby.”