In December 2020, the Ockenden Maternity Review was published which looked into the failures in maternity care at Shrewsbury and Telford Hospitals NHS Trust. The Review was published following several cases of alleged neglect and preventable baby deaths at the Trust over decades.
The Ockenden Report identified problems with leadership as one of the main issues in the failures at Shrewsbury, as well as issues with maternity and neonatal units working together. Donna Ockenden, former Senior Midwife, advised that there was a culture of blaming parents for preventable deaths and failing to listen to the families. The Report also highlighted that the Trust often failed to learn from previous mistakes, by tending to focus on the actions of the parents, rather than failures within their departments.
The Report urged Trusts to work together when investigating serious incidents, to ensure that learning is shared across regions, to prevent further mistakes. Donna Ockenden also recommended that staff need to be given training for different disciplines, as well as a culture change that allows midwives to feel able to discuss problems with senior midwives and obstetricians.
The Care Quality Commission reported that almost two thirds of all maternity units in England were in need of improvements in safety.
As a response to the Ockenden Review, the Government have announced a £500,000 programme to provide hundreds of maternity and neonatal leaders across 126 Trusts with further training. There will also be seven regional chief midwives and a maternity safety champion in each Trust. It is hoped that the introduction of these roles will help to make maternity services safer and more personal for women and babies.
The aim of the programme is to provide maternity leaders with the skills to improve the collaboration between nurses, doctors, midwives and obstetricians. Staff will be encouraged to anticipate risks for mothers and babies, and put measures in place to either avoid or respond to these risks should they materialise. It is hoped that by changing the environment within maternity departments, there will be much fewer preventable baby deaths.
The programme, which will be rolled out later this year, also hopes to establish a core curriculum for all maternity services, to ensure that skills and training are consistent throughout the country.
Maternity leaders will be trained in how to engage appropriately and sensitively with families following tragic outcomes, to help families to understand what has happened, while also providing them with the opportunity to discuss with the maternity and neonatal units any concerns that they may have.
The announcement of the Government’s programme is certainly a promising step towards improving maternity services. Time will tell whether it leads to any noticeable improvements.
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