'I am sorry to those of you we've let down': Hospital boss outlines maternity services improvements

Donna Ockenden’s Independent  Review of Maternity Services at Shrewsbury and Telford Hospital NHS Trust (SaTH) highlighted significant failings following its publication in 2022.

Her review examined maternity practices at SaTH over 20 years and found the failures there contributed to the deaths of 201 babies and nine mothers, and left other infants with life-changing injuries.

Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

Several mothers were made to have natural births despite the fact they should have been offered a caesarean.

The report examined cases involving 1,486 families, mostly from 2000 to 2019, and reviewed 1,592 clinical incidents.

A review of 498 stillbirths found one in four had "significant or major concerns" over the maternity care given, which, if managed appropriately, might, or would have, resulted in a different outcome. Some 40% of these stillbirths were never investigated by the trust.

There were also "significant or major" concerns over the care given to mothers in two-thirds of cases where the baby had been deprived of oxygen during birth.

Overall, there were also 29 recorded cases where babies suffered severe brain injuries and 65 cases of cerebral palsy.

Nearly a third of neonatal deaths had "significant or major concerns" over care. Yet the trust had only looked at 43% of these.

Overall, 12 deaths of mothers were investigated, none of whom received care in line with best practice at the time. In three-quarters of these cases, care "could have been significantly improved".

Some women were blamed for their own deaths, the report found, while incidents that should have triggered a serious incident investigation were "inappropriately downgraded" by the trust to its own series of "high risk" case reviews, which were "apparently to avoid external scrutiny".

The trust has since accepted the findings of the report and has vowed to address the 210 improvements to its service it outlined.

In an open letter, Chief Executive Louise Barnett has detailed the work done at the trust since the publication of the Ockenden report, and has asked anybody affected by the issues raised in the report to get in touch.

She said: “Donna Ockenden’s report highlighted significant failings in the Trust’s maternity services over the last two decades which we  accept fully. 210 actions for improvement were identified which we fully support. We began work immediately on delivering and  embedding these actions in a meaningful and sustainable way. This has been much more than just working our way through each  action. We are determined to make this a permanent change to the way we work.”

She continued: “In the last four years, we have focused on improving our maternity services and making them safer for women and families. It is  important that we always remember that these improvements have been a direct response to families bravely coming forward to  describe their experiences of care in our hospitals.

“As of today, through our Maternity Transformation Programme (MTP), we have implemented 195 (93 per cent) of the 210 actions from the Independent Review of Maternity Services, and continue to work on the  remaining 15 actions, with our colleagues and system partners.”

She said the trust now had “robust training programmes” in place that equip the maternity workforce with up-to-date skills, training, and development, including the management of emergency scenarios.

A risk assessment was also now is undertaken at every antenatal appointment, on admission during labour, and is undertaken as part of hourly  reviews when a woman is in labour. SaTH is also offering a range of improved options of listening to women and families, including a birth options clinic and birth preferences  card to help women decide on their preferred way to have their baby

A resident consultant obstetrician is also now on duty in its delivery suite 24 hours a day to provide our staff with high quality medical leadership and support when it is needed, and fetal monitoring training has been improved and now includes a full day of face-to-face training with assessment at the end of the  day

“Staff have learnt to work in a different way, are better trained, use  better guidance and listen carefully to families to make sure that care is as personalised, but also as safe as it can be,” said Ms Barnett. “As with all improvement work, there is always more to do, and this is where we would welcome your help and support to enable  the Trust to make further improvements in the services we provide to our families.”

She added that while SaTH had tried to communicate to those affected by the issues highlighted by the Ockenden report, she acknowledged that some families had not had the direct contact they would have liked.

“I  am sorry to those of you we have let down, as that has never been our intention, and we would like to address this,” said Ms Barnett. “We have had contact with many families affected by the Independent Review of Maternity Services and other families not included in the  review. We would like to take this opportunity to hear directly from anyone who would like to engage with us and we will make all  necessary arrangements for this to happen.

“We genuinely wish to engage with families more so that we can learn and improve further, and we are exploring more ways to do  this better. If you would like to get in touch with us please do so via the following email address: sath.maternitycare@nhs.net and  we will get back to you as soon as possible.”

The full letter is available on the SaTH website.