An independent inquiry investigating maternal and baby deaths at an NHS Trust in Shropshire has made damning findings in its initial report, and recommends “immediate and essential actions” nationwide to improve maternity services.
The inquiry, headed by ex-midwife Donna Ockenden, was set up in 2017 to examine 23 cases of deaths and allegations of negligence under the maternity service at Shrewsbury and Telford Hospital NHS Trust (SaTH). However, the inquiry was quickly contacted by hundreds of families and in total, it has examined nearly 2,000 cases of families where incidents took place between 2000 and 2019.
There have been numerous serious and substantial failings of care provided by SaTH. Of the identified failings, one startling revelation was that families reported a complete lack of basic kindness and compassion from members of the maternity team when responding to a patient death, with staff either using inappropriate distressing language; having their concerns dismissed or not listened to; and even blaming families for their loss which compounded their grief.
The Inquiry also discovered that many mothers were given a drug – oxytocin – without assessment of risk during labour, contrary to national guidelines, which led to significant numbers of babies being born with catastrophic brain injuries and death. It also discovered that despite multiple babies being born with brain injuries, there was no review carried out by the Trust who did not learn from previous cases where the outcome was poor.
The report recommends 27 immediate and essential actions which should be carried out in all NHS Trusts’ across England. Patient Safety and Maternity Minister Nadine Dorries has indicated that it will now work with NHS England and Improvement to ensure the recommendations are acted upon.
A clinical negligence solicitor at Sydney Mitchell, said:
The initial report of Ockenden Inquiry is devastating to read, and my heartfelt sympathies are with every family who has been affected by the shocking failings by SaTH’s maternity services. As with all medical negligence cases, families only want two things: firstly, they want questions answered in order that they understand what happened during their care; and secondly, they want the system to learn, so as to ensure that any identified failings from their care are not repeated in the future. It is therefore disappointing that it has taken a formal inquiry for families to get the truth and to ensure that their voices have been heard. However, It is reassuring that recommendations have been made not only for SaTH but for all NHS Trusts across England to ensure that patient deaths and injuries are avoided. The NHS must now act swiftly and decisively, and must learn from these tragic mistakes without unnecessary delay.
For help or advice on clinical negligence matters, please a member of the PI team on 0808 166 8827.
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