Shrewsbury and Telford Hospital - Getty editorial

Interim report into maternity care at Shrewsbury and Telford NHS Trust

An interim report into maternity care at Shrewsbury and Telford NHS Trust says it is the biggest maternity scandal in the history of the NHS and calls for urgent changes to care given in hospitals across the country to prevent more avoidable baby deaths, stillbirths and neonatal brain damage, reports The Guardian.

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Posted on 10 December 2020

The report reveals that more than 13 women and 40 babies died during childbirth in the care of the trust’s hospitals because of a culture that denied women choice and subjected hundreds of families to unsafe care, reports the Independent.

In her Emerging Findings report, published in advance of the full report in 2021, midwife Donna Ockenden says:

“We implore maternity services across England to also carefully consider this first report, and to make ambitious plans to ensure timely implementation of these Local Actions for Learning and Immediate and Essential Actions takes place.

Her report includes recommendations for all hospital trusts to improve maternity safety “at pace, including risk assessment at every antenatal contact and twice-daily consultant-led maternity ward rounds. The trust has also been told to improve its investigation of incidents. The 27 recommendations for better care also include better information and choices offered to women and improvements in baby monitoring and instructions that staff follow official guidance on care and use of oxytocin.

Ms Ockenden says: “The families who have contributed to this review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past.”

Her report reveals that a culture within the Shrewsbury trust to keep caesarean section rates low resulted in harm. The trust had caesarean section rates consistently between eight and 12 per cent lower than the average for England.

It said mothers had not been warned of the risks of giving birth in standalone midwifery led units far from hospitals which in some cases led to catastrophic events including deaths, reports the Independent, which adds that the “clinical care and decision making of the midwives did not demonstrate the appropriate level of competence” including failures to recognise when there were problems with births.

A full report on the trust and considering all 1,862 cases will be published in 2021.

Essential actions called for are:

Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks.
Neighbouring Trusts must work collaboratively to ensure that local investigations into Serious Incidents (SIs) have regional and Local Maternity System (LMS) oversight.
Maternity services must ensure that women and their families are listened to with their voices heard.
Staff who work together must train together.
There must be robust pathways in place for managing women with complex pregnancies
Through the development of links with the tertiary level Maternal Medicine Centre there must be agreement reached on the criteria for those cases to be discussed and /or referred to a maternal medicine specialist centre.
Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway.
All maternity services must appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion best practice in fetal monitoring.
All Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.

The report is as bad as we had feared and bears out the many cases we have represented of poor maternity care across the country."

Suzanne White, head of medical negligence

The independent review was ordered by former health secretary Jeremy Hunt in 2017 after two sets of parents who had both lost children through avoidable medical errors raised concerns about care.

The trust in charge of both hospitals was placed in special measures, in part due to its maternity units in late 2018. No other trust in England has as many conditions on its licence as Shrewsbury and Telford, reports the BBC

Leigh Day head of clinical negligence Suzanne White, who this year secured a settlement of more than £30 million for a child who was starved of oxygen at birth, said:

“The report by Donna Ockenden is as bad as we had feared and bears out the many cases we have represented of poor maternity care across the country. We know that what has been exposed at Shrewsbury, and earlier at Morecambe Bay, and more latterly at East Kent, is representative of poor care that women and families experience in maternity units across England.

"We represent many families whose experience is similar. We all hope that this report, like others, will at last make for necessary change to improve care for women at a time that they should be able to expect the best and not, as is so often the case, a tragic outcome.”

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