Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust
News and Updates
Care Quality Commission (CQC) statement following the publication of the first report
Professor Ted Baker, Chief Inspector of Hospitals, said:
“The death or injury of a new baby or mother is a devastating tragedy and something that everyone working in the health and care system must do all they can to prevent. “The emerging findings from Donna Ockenden’s review make for difficult reading. Limited oversight of risk, insufficient safety training for staff, poor communication with families, and a lack of robust investigation or learning when errors were made. Sadly, these are all themes that have been identified before, but yet again it has taken the repeated persistence of campaigning families and patients to bring them to the fore.
“The continued national focus on the safety of maternity services is welcome – and we are seeing some positive change. However, the progress made does not yet meet the scale of the challenge.
“As we set out in our Getting Safer Faster briefing earlier this year, there needs to be concerted national action and accelerated efforts to ensure that improvements in safety are achieved with the urgency required. A major factor in this is the need to drive a change in culture that means the voices of staff, patients and their families are listened to and acted on. Without this shift we will not move forward. “We welcome the recommendations set out by Donna Ockenden and her team and will monitor their implementation by the Trust, as well as working with the Department of Health and Social Care, NHS England/Improvement and wider system partners to play our part in supporting implementation.
West Mercia Police statement following the publication of the first report
Assistant Chief Constable for West Mercia Police, Geoff Wessell, said: “Our investigation is running concurrently to the Ockenden Review and we have had sight of the report that has been released today.
“We are mindful that the families involved with the review have waited patiently for the initial learning actions outlined in the report. I want to reassure them, and the wider community, that our investigation will, in no way, impede the work of the Ockenden Review or prevent the actions outlined in today’s report from being implemented.
“Our investigation into maternity services at the Trust remains ongoing and, as such, we are not in a position to release any further information at this time. When there is an update we can provide we will share this with the families involved first and foremost and then to the wider public.”
The Shrewsbury and Telford Hospital NHS Trust response to Donna Ockenden’s first report following the Independent Review of Maternity Services (10th December2020)
We now have a provisional date of the 10th December, subject to the Parliamentary timetable permitting, for the first report into maternity services at the Shrewsbury and Telford NHS Trust (SaTH). This will be an emerging findings report and will include ‘Essential and Immediate Actions’, as a result of our review of a selection of 250 cases of concern, which include the original 23 cases which initiated this independent maternity review. The emerging findings report will include ‘Essential and Immediate Actions’ which we feel are necessary to ensure safe practice in maternity services at SaTH and will make a difference to the safe provision of maternity services elsewhere.
Listen to a short message from Donna Ockenden as Baby Loss Awareness Week 2020 commences
Please see attached a news release announcing a new ’Improvement Alliance’ between The Shrewsbury and Telford Hospital NHS Trust and University Hospitals Birmingham NHS Foundation Trust.
MPs call for evidence on maternity safety and what more must be done to improve it.
Recurrent failings in maternity services and what action is needed to improve safety for mothers and babies is the focus of this new inquiry launched by the Health and Social Care Committee. The Safety of Maternity Services in England inquiry will examine evidence relating to ongoing concerns despite the substantial amount of work carried out in recent years.
The Committee will build upon investigations that followed incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust.
MPs will also consider whether clinical negligence and litigation processes need to be changed to improve the safety of maternity services, as well as the extent to which a “blame culture” affects medical advice and decision-making.
Health and Social Care Committee Chair Rt Hon Jeremy Hunt MP said:
“The death of a baby when something goes wrong is a tragedy for a family. When we’ve seen a pattern of baby deaths, we must be confident that failings that contributed to them have been addressed and lessons learned.
“However, the safety of our maternity services continues to be a matter of concern.
“We’ll be looking at the evidence that’s been gathered to date and whether recommendations are being acted upon to ensure that lasting improvements are made to safeguard the lives of mothers and their babies.”
Press Release from Donna Ockenden
INDEPENDENT REVIEW INTO MATERNITY SERVICES AT THE SHREWSBURY AND TELFORD HOSPITALS NHS TRUST ENTERS NEXT PHASE
Donna Ockenden, Chair of the Independent Maternity review into care at The Shrewsbury and Telford Hospitals NHS Trust has confirmed today that the total number of family cases the review team is now looking into stands at 1862.
Following an ‘Open Book’ review in 2018 which largely focused on electronic records, a call for families to come forward and a further search of paper records a further 496 families were identified to give 1862 cases.
“The Trust have worked closely with the review team throughout this process and have provided us with all requested information. I would like to thank them for all the work undertaken to reach this point. By working together we have sadly identified a further 496 families as part of the review, who I am writing to this week.”
Families who wish to raise a concern about the care they have received, should do so directly with the Trust by contacting: [email protected] or by phone to the Patient Advice and Liaison Service on: 01952 641222 extension 4382.
All efforts are now focusing on the completion of clinical reviews by the independent maternity review team to enable the final report to be published. Donna Ockenden further explained:
“it’s now really important that we focus our efforts on getting all clinical reviews completed so that we can make meaningful recommendations to improve services and give families the answers they have asked for. We intend to have initial, emerging recommendations for maternity services published at the end of the year.
In order to give ourselves the time to write the final report, any new cases that come to light from now on will need to go directly to the Trust, for them to consider, rather than them coming to the maternity review team.”
These additional families will be written to telling them that their maternity care at The Shrewsbury and Telford Hospitals NHS Trust has been referred to the independent review team. The letters to families discuss the Terms of Reference which explain the work of the Independent review team. The Terms of Reference can be found here:
The letters also provide information to enable families to make a choice as to whether they want their care to be reviewed by the independent team.
Donna Ockenden finished by adding:
“I have made a commitment to the Secretary of State for Health and Social Care that we will undertake our work with the care and the independence it deserves and we will publish the final report as quickly as we can. I want to assure families that their experiences are important to us and that our independent team of midwives and doctors continue to ensure that family voices remain central to everything we do.”
This Independent Maternity review was commissioned by Jeremy Hunt in 2017, when he was Secretary of State for Health and Social Care, following concerns raised by the parents of Kate Stanton-Davies who died shortly after birth in 2009 and Pippa Griffiths, who died just after she was born in 2016.
An open letter to the people served by The Shrewsbury and Telford Hospital NHS Trust
I know that you, the communities of Shropshire, Telford & Wrekin and mid Wales care deeply about your local hospitals and the care we provide. All of us experience important life events in hospitals, from the birth of a loved one, to life-changing surgery or treatment in an emergency. You have a right to expect the very best care every time you use our services. However, if things do go wrong, it is the role of the Trust and our staff to learn from any failings, so that we can provide answers to families and patients and improve our care now and in the future.
You will, of course, be aware that our Maternity Services have been under the spotlight for some time. I know that our standards of care have fallen short for many families and I deeply apologise for this.
An independent review, led by experienced midwife, Donna Ockenden, is looking into cases involving families from our communities. Today, we know that the total number of families whose cases are being reviewed is 1,862. I recognise that this will be a huge concern, both for those families and everyone in our communities, who depend on us for their care.
It is a concern for our staff too, who are committed to providing our patients with the highest standards of care.
There is no doubt that this continues to be a difficult and painful experience for many families and I am truly sorry for their distress. I recognise that we should have provided far better care for each and every one of these families at what was one of the most important times in their lives. We know that we have let them down.
I am very aware that, for these families, words will never be enough and what they want to see is evidence of real improvement at the Trust. This is why we are committed to listening to them and to working with Donna Ockenden’s Review to ensure lessons are learned and we have a service which the community and our patients can trust.
We have made some progress in improving the standards of care for mothers and babies and the Care Quality Commission (CQC) now rates our Maternity Services as ‘Good’ across three of the five standards (Caring, Effective and Responsive). However, we are rated as ‘requires improvement’ for the other two standards (Safe and Well-led). We recognise that we still have a long way to go.
One of the things we have learned is that we must be better at listening to everyone who uses our services. We will work harder at this and create more opportunities for families to tell us about their experiences, allowing us to make positive, clear and tangible improvements, based on what we learn.
Our opportunity to listen and learn should not be confined to the families involved in the Ockenden Review. Any family not included in the review can come to us at any time to share their experiences or raise any concerns. You can contact us by email: [email protected] or by phone to Patient Advice and Liaison Service on: 01952 641222 extension 4382.
We must now let Donna and her team do their job and we will continue to work openly with them to help families get the answers they need and in turn for us to make the necessary improvements.
In the meantime I want to reassure you that we are working hard to deliver the high quality Maternity Services that the people in our communities rightly deserve.
Chief Executive, The Shrewsbury and Telford Hospital NHS Trust
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