Ockenden Independent Review Calls For 'Immediate And Essential' Action To Improve Safety In Maternity Care

The Ockenden Review of Maternity Services at Shrewsbury and Telford Hospital NHS Trust has called for ‘immediate and essential’ action across maternity services in England to improve maternity safety.

What is the Ockenden Review?

The Ockenden Review is an ongoing, independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (the Trust), chaired by midwifery expert, Donna Ockenden. The review was set up in response to former Secretary of State for Health and Social Care, Jeremy Hunt’s request for an ‘independent review of the quality of investigations and implementation of their recommendations of a number of alleged avoidable neonatal and maternal deaths, and harm at The Shrewsbury and Telford NHS Trust’. As more families came forward, the scope of the review increased from an initial 23 cases to over 1800 cases of avoidable harm which occurred at the Trust between 2000 and 2019. These included stillbirths, neonatal deaths, maternal deaths, babies brain injured from HIE, and other severe injuries to mothers and newborn babies.

The completed review will involve the largest number of clinical reviews of any inquiry into a single service (in this case maternity) in the history of the NHS. So far, the review team have fully assessed 250 cases and talked to a further 800 families about their own concerns. This interim report identifies the main safety themes that have emerged so far and demands that immediate action is taken nationally to improve maternity care.

Shrewsbury and Telford Hospital NHS Trust must act to avoid harm - maternity safety themes so far

The Ockenden Review made specific recommendations for action the Trust must take urgently to reduce the risk of further harm in areas where key themes have been identified so far. The review’s preliminary investigations of avoidable harm to mothers and babies at the Trust demonstrate failings at every level of the Trust’s maternity care. These failings included the constantly changing leadership team’s dismissal of problems as ‘historic’, lack of consultant involvement and multi-disciplinary teamwork, poor systems, and clinical incompetence at all levels. There was a ‘disappointing’ and ‘deeply worrying’ lack of kindness and compassion from maternity staff, including cases where bereaved women were blamed for their loss, and a failure to listen to women and their families about concerns related to their care.

Risk assessment and planning failures led to lack of informed consent or maternal involvement in decision-making in relation to the most appropriate place of birth. Mothers with high-risk pregnancies were managed by midwives or junior doctors, with inadequate consultant supervision. Midwives failed to recognise or escalate potential complications as they arose, and those that were escalated were not acted upon by the doctor or escalated further for consultant review.

Clinical incompetence included incorrect fetal heart monitoring, interpretation of CTG traces and use of oxytocin (Syntocinon). Even consultant obstetricians were found to have caused traumatic birth injuries by repeated or excessively forceful attempts at vaginal delivery with forceps, in cases where vaginal delivery was inappropriate or should have been abandoned and the baby delivered by caesarean section. Women were not allowed to choose or express a preference for a caesarean section. These problems may have led to babies been harmed as the culture at the Trust prioritised the importance of low caesarean section rates.

Maternal deaths had arisen where women with significant health conditions or risk factors were left in the care of junior medical staff without input from consultant obstetricians, consultant obstetric anaesthetists or multidisciplinary specialists. Mistakes included failure to recognise a deteriorating patient, delayed initiation of investigations, treatment, escalation and transfers to the high dependency unit or intensive care. 
There was a lack of involvement from consultant anaesthetists in maternity care. Anaesthetic care was focussed on single tasks, such as siting an epidural without considering the woman’s overall condition. Women with complex obstetric complications, such as severe sepsis or pre-eclampsia, or with significant health conditions, were treated by junior staff for long periods of time. Escalation to the consultant anaesthetist was delayed. Even when called, consultant anaesthetists failed to attend in a timely manner.

Immediate and Essential Actions to Improve Care and Safety in Maternity Services across England

Even as a birth injury specialist, I have been shocked by the scale of the harm and suffering caused by the Trust to more than 1800 families. However, I believe it is important to recognise that similar failings continue to cause avoidable harm and lifelong suffering to mothers, babies and their families in hospitals across the country, albeit hopefully on a much smaller scale.

The Ockenden Review quite rightly recognises that the NHS as a whole must now learn from the themes and lessons that are emerging from Shrewsbury and Telford Hospital NHS Trust, and has specified how it must do so with a set of ‘immediate and essential actions’. The review points out that many of their ‘immediate and essential actions’ for NHS maternity services are not new but observes that much of the harm that they are currently investigating arose from failure to implement recommendations from previous maternity safety reports. They emphasise that the following actions must be implemented now.

Recommendations for safety include:

• Neighbouring trusts working together to ensure that local investigations into serious incidents and clinical change are regularly overseen by regional and local maternity systems (LMS). 
• Clinical specialist opinion from outside the Trust must be mandatory for cases of intrapartum fetal death (stillbirth), maternal death, neonatal brain injury and neonatal death.
• All maternity serious incident reports must be sent to the Trust Board and local LMS for scrutiny, every 3 months.

Recommendations for listening to women and families include:

• Maternity services must ensure that women and their families are listened to with their voices heard.
• An accountable, independent senior advocate must be available to families attending meetings with clinicians to discuss concerns about maternity or neonatal care, particularly where there has been an adverse outcome. 
• A non-executive director must oversee maternity services to represent women and family at trust board level.
• CQC inspections must include assessment of whether women’s voices are truly heard by the maternity service.

Recommendations for staff training and working together include:

• Staff who work together must train together. 
• Trusts must demonstrate multidisciplinary training and working, including twice daily, consultant-led multidisciplinary labour ward rounds. 
• Funding allocated to training of maternity staff must be used for this purpose only.

Recommendations for complex pregnancy include:

• Women with complex pregnancies must have a named consultant lead, early specialist involvement and a management plan agreed between the woman and the team. 
• Maternal medicine specialist centres must be developed as an urgent, national priority, to allow early discussion of complex maternity cases with expert clinicians, with agreed criteria for cases to be discussed or referred. 

Recommendations for risk assessment throughout pregnancy include: 

• All women must be formally risk assessed at every antenatal contact to ensure they have access to care from the most appropriately trained professional. Risk assessment must include ongoing review of the intended place of birth, based on the developing clinical picture.

Recommendations for fetal monitoring include:

• All maternity services must appoint a senior and skilled dedicated Lead Midwife and Lead Obstetrician to champion best practice in fetal monitoring, gather, update and share knowledge, provide support and training to colleagues, and lead the review of adverse outcomes involving poor fetal heart rate interpretation and practice.

Recommendations for informed consent and decision-making include: 

• Women must have access to accurate, up to date information which complies with national guidelines so they can participate equally in decision making and make an informed choice about place and mode of birth, including maternal choice for caesarean delivery. This applies to antenatal, intrapartum and postnatal care. 
• Women’s choices following a shared and informed decision-making process must be respected.

What happens now?

The review stressed the importance of immediate action if further harm to mothers and babies is to be avoided. Their call for action is supported by both the RCOG and the RCM. Nadine Dorries, the Minister of State for Mental Health, Suicide Prevention and Patient Safety, has also welcomed the recommendations in the report, saying the DHSC is working closely with NHS England, NHS Improvement, and the Trust, to take each of the recommendations forward. 

Meanwhile, we await the Ockenden Review’s full and final report, which is due later this year.

If you or a member of your family have suffered serious harm as a result of maternity care negligence and you would like to find out more about making a claim for compensation, contact us by email on cerebralpalsy@boyesturner.com.