Ockenden Review on Maternity Services
The Independent review of maternity services by Donna Ockenden was commissioned in 2017 by NHS Improvement on behalf of Jeremy Hunt, the former Secretary of State for Health and Social Care. Concerns were made by parents who attended the Shrewsbury and Telford Hospital NHS Trust about the quality of care and failures resulting in many deaths over two decades.
Jacqueline White, Head of Medical Negligence at Pearson Solicitors and Financial Advisers gives her thoughts on the Ockenden Maternity Review.
“The findings of the investigation into maternity care at Shrewsbury and Telford Hospitals NHS Trust over the last 20 years make for harrowing and disturbing reading. Whilst the focus of this investigation has been on Shrewsbury and Telford, Ockenden’s findings are common to Hospital Trusts and maternity services across the country – failures to listen to parents, failures to learn and failures to improve.”
“Such failures have and will continue to result in avoidable still births, post-natal deaths and severe life limiting brain injuries and conditions such as Cerebral Palsy. Parents are then left with a lengthy fight for justice and the financial compensation required to support a child with neurological deficit.” she added.
The investigation into the Maternity Services
The Chair of the Maternity investigation 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 foetal 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, mothers 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 of 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.”
Roadmap of Maternity Services
The maternity review sets out a roadmap of four key pillars that are essential changes to improve safety:
- Staffing levels that are properly funded
- A well trained workforce
- Learning from incidents
- Listening to families
Medical Negligence Solicitor Jacqueline White concluded:
“Let’s hope that this enquiry is the last of its kind and that lessons will be learned, not only by Shrewsbury and Telford but by all UK Hospital Trusts. The mistakes of the last 20 years cannot be fixed, the lives ruined can never be truly mended, but action can be taken by those involved in maternity care to ensure that the next 20 years sees improvement in the safety, care and treatment of expectant Mothers and their babies.”
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