Publication of the final Ockenden Report into Shrewsbury and Telford Hospital NHS Trust

Post by: Charley Turton

Today the Ockenden report into failings in maternity care at the Shrewsbury and Telford Hospital NHS Trust has been published.

Vanessa Cashman of 12KBW’s clinical negligence team will bring you a blog post offering analysis of the report in the coming weeks.

For those of you who cannot wait that long, here is my executive summary of the executive summary (!) to whet your appetite and orientate your reading of the mammoth 250-page report.

  • The review covered all aspects of maternity care at Shrewsbury and Telford.
  • The scope of the review increased considerably: from 23 cases of concern in 2017, it grew to encompass the care provided to 1,486 families.
  • The report places particular emphasis on the voices of family members and staff, although some staff withdrew their cooperation with the report through fear of being identified.
  • The review found patterns of repeated poor care:
    • Errors in care leading to injury to babies and mothers, including:
      • Failure to check for gestational diabetes.
      • Lack of appropriate fetal heart rate monitoring during labour.
      • Reluctance to refer to specialists.
      • Failure to discuss patients with the wider multidisciplinary team.
      • Delay in conducting emergency caesareans.
    • Poor investigation of cases.
    • A lack of transparency and dialogue with families.
  • The review found evidence of a ‘them and us’ culture between the midwifery and obstetric staff which acted as a barrier to escalating cases to the appropriate clinician. Delays in escalation were exacerbated by staffing and training gaps at the Trust.
  • The outcomes for mothers or their babies included sepsis, hypoxic ischaemic encephalopathy and, tragically, death. The review considered 12 cases of maternal death and 498 cases of stillbirth.
  • The review makes recommendations to be considered by all trusts in England providing maternity services, not just Shrewsbury and Telford.
  • Recommendations for improvement include:
    • significant investment in the maternity workforce and multi-professional training.
    • suspension of the Midwifery Continuity of Carer model until, and unless, safe staffing is shown to be present.
    • strengthened accountability for improvements in care amongst senior maternity staff, with timely implementation of changes in practice.
    • improved investigations involving families
  • There has been some progress since the first Ockenden report in December 2020 including, for example, the employment of increased numbers of senior clinicians.

You can read the full report here.

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