Maternity Scandal: Report Finalised

In 2019, the biggest maternity scandal in Shrewsbury and Telford Hospital Trust’s history came to light. Hundreds of families came forward, telling their stories of how the Trust had failed them and their babies. This led to an inquiry into 1,592 clinical incidents involving 1,486 families between 2000 and 2019. This inquest was headed up by a senior midwife, Donna Ockenden.

My colleague, Wioleta Dworak, wrote about the scandal when it first emerged. You can read this post here.

The report has now been released and has identified many changes that must be made.

Outcomes

Sadly, the inquest identified that the failures of the NHS Trust may have led to the death of over 200 babies, and 9 mothers. Mistakes made were not investigated, and this led to them being repeated, causing further loss.

The report identified that 201 babies could have survived if the NHS Trust had provided adequate care. There were also 29 cases where babies were left with severe brain injuries, as well as 65 cases of cerebral palsy (CP).

CP can sometimes occur during or shortly after birth, a common cause being a lack of oxygen reaching the baby’s brain during labour. There are several complications that increase the risk of reduced oxygen getting to the baby’s brain, that maternity staff can look out for. These are:

• Prolonged labour
• Abnormal birth position
• Placental abruptions

The above complications often lead to foetal distress, causing a decision to be made to proceed with a Caesarian Section. However, the report found that there were several cases where Caesarean Sections were not performed despite a mother’s request for one. There were even cases identified where a Caesarean Section was discouraged by maternity staff.

Ms Ockenden commented on the apparent reluctance to perform Caesarean Sections as a repeated problem that "resulted in many babies dying during birth or shortly after".

Immediate and Essential Actions

An area that the Ockenden report placed a lot of focus on is improvements to the training of maternity staff. The report endorses the Health Select Committee’s view that a proportion of maternity budgets should be ring-fenced to dedicate to training purposes. The report recommends that this should be reported by the Trust publicly in their annual Financial and Quality Accounts. It also recommends that there should be a single set training target across all maternity services in England. Implementing measures such as this should ensure that the NHS continues to have maternity staff with the latest training and also provides a clear and consistent target across all services.

The report encourages the NHS Maternity Digital Programme. This is the use of digital maternity notes. This would be a great step forward in improving the services provided by the maternity staff, as there is less chance that notes are lost or misread. The investigations carried out before the report found that key medical information was being written on post-it notes and then thrown away by cleaners. This would remove such a risk. It will also support mothers, as they will have their digital maternity care plan and record, discussed and agreed with them and their midwife. Improving communication will ultimately lead to better and safer care for both mothers and babies. This will be a very important step to implement moving forward.

Future concerns

While the failures identified in the report are concerning enough, there are still fears amongst NHS and midwifery officials that an ever-growing shortage of maternity staff in the UK could mean that the improved standards called for in the report may not be met. 

With the final Ockenden report now published, the spotlight is on the NHS to take forward the recommendations that are made and ensure that they are implemented. This will not be a problem that is fixed overnight. However, there are now high expectations from both the families already affected by poor care and future families who will have to rely on maternity services to start seeing changes.