An independent review by senior midwife Donna Ockenden into what has been described as the biggest maternity scandal in the history of the British National Health Service has called for urgent changes in all hospital trusts in England to prevent more avoidable baby deaths, stillbirths, and neonatal brain damage, reports MedicalBrief.
The review, commissioned in 2017 into the care of mothers and babies who died at Shrewsbury and Telford NHS Hospital Trust (SaTH), said immediate action was needed to improve maternity safety. It identified 1,862 cases, mostly between 2000 and 2019 for its investigation.
The interim report followed a review of 250 of the cases in which families had "shared with us their accounts of the overwhelming pain and sadness that never leaves them". The Royal College of Obstetricians and Gynaecologists (RCOG) said the recommendations made "difficult reading" but should be acted on immediately.
Essential actions called for by the interim Ockenden report are:
- Strengthening safety in maternity units by increasing partnership between trusts and within local networks;
- Ensuring that maternity services listen to women and their families;
- Making sure that staff who work together, train together;
- Establishing robust pathways for managing women with complex pregnancies;
- Ensuring that women undergo risk assessments throughout their pregnancy;
- Establishing dedicated and experienced 'lead midwives' and 'lead obstetricians' to ensure best practice in foetal monitoring; and
- Ensuring that women have accurate information to enable them to make informed choices about intended place and mode of birth
The Guardian reports that the Ockenden report identifies a "lethal reluctance to conduct caesarean sections; a tendency to blame mothers for problems; a failure to handle complex cases; a lack of consultant oversight, and a 'deeply worrying lack of kindness and compassion'. In June 2020, West Mercia police launched an investigation into the worst of the cases.
The failings identified at SaTH typify mounting concerns about safety and potentially avoidable deaths at other maternity services. In September, MPs were told that 38% of maternity services were deemed to require improvement for patient safety and some could get even worse.
Rhiannon Davies, who lost her daughter Kate in 2009, told The Guardian: “There is a deep-seated problem in maternity, a deeper-seated problem in midwifery and a toxic issue at the heart of SaTH’s specific midwifery and obstetric services.”
She added: "Women are not aware of the risks they and their baby face during labour and birth … In terms of midwifery, there is a culture of normal birth at any cost. This has pervaded for decades. It comes from the ideology behind current midwife training. That has to change."
Louise Barnett, SaTH’s chief executive, said it would implement all the recommendations in full. She said: "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. 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."
[link url="https://www.donnaockenden.com/downloads/news/2020/12/ockenden-report.pdf"]Full Interim Ockenden Report[/link]
[link url="https://www.theguardian.com/society/2020/dec/10/maternity-scandal-report-calls-for-urgent-changes-in-englands-hospitals"]Full The Guardian report[/link]