On the 30th March 2022, the eagerly awaited Ockenden Report was published, examining the care that has been provided by Shrewsbury and Telford NHS Trust, at Royal Shrewsbury Hospital and Princess Royal Hospital, over the last 20 years.

Donna Ockenden, former Senior Midwife, has been reviewing potential failures in the maternity care, following several cases of alleged neglect and preventable deaths at the Tru

st. In a letter to the Secretary of State, Ms Ockenden stated:

“This final report of the Independent Maternity Review of maternity services at the Shrewsbury and Telford Hospitals NHS Trust is about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve, and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives.”

The review looked into cases for 1,486 families, and represents the largest investigation into a single NHS Trust in history.

Sadly, the Report has found that catastrophic failures by the Trust, may have lead to the deaths of 201 babies and 9 mothers. There were also 29 incidents that lead to severe brain injuries for the babies, and 65 babies that have since been diagnosed with cerebral palsy.

As part of the review, 12 cases of mothers that had died were considered by the review team. The team determined that none of the mothers had received care that would be considered best practice.

One of the main issues that has been highlighted, was the failure to investigate incidents, which lead to families feeling as though they had not been listened to and lessons were not learnt, which means that failures were repeated. Ms Ockenden states that there was tendency to focus on the actions of the parents, and in some cases put blame on the mothers, even for their own deaths, rather than accept failures within their departments.

Ms Ockenden states within her Report that the culture within the Trust lead to fear of speaking out about concerns, and a failure to properly examine cases. Where incidents were investigated, she describes the Trust’s responses as lacking “transparency and honesty”. Between 2011 and 2019, only 60% of stillbirths and 57% of neonatal deaths were investigated.

The Report highlights cases of failing to effectively monitor foetal growth, as well as a reluctance to perform Caesarean sections, even in cases where this resulted in the death of the baby during labour, or shortly afterwards. Ms Ockenden believes that the failures were primarily due to a lack of staff, a lack of training and lack of effective investigation, allowing people to learn from mistakes.

The Trust has apologised to the families that have been affected, and has stated that new measures have already been introduced to try and improve the standard of care that is provided.

What will happen now?

In her Report, Ms Ockenden has identified 60 improvements that should be made going forwards to learn from these mistakes.

The families that were consulted as part of this Review, have been incredibly brave, to discuss the events that occurred and to highlight their concerns, in the hope that mistakes won’t be repeated. The next step is to ensure that improvements are made and that faith can be restored in the maternity services.

Last week, NHS England announced a £127 million funding boost for maternity services to help ensure safer care for mothers and their babies. It is hoped that the investment will boost the amount of staff as well as improving the culture within the departments. More than £50 million is given to Trusts to boost staffing over the next two years, and £34 million will be invested in leadership development programmes. The remaining capital will be used to increase the number of neonatal cots and other equipment within hospitals, to ensure new-born babies receive the best quality care.

How can we help?

If you are concerned about the care that you received at a maternity unit, we may be able to help you. Please get in touch to discuss the circumstances surrounding your care with a member of our specialist clinical negligence team.

It is important to recognise that there is a time limit that applies to clinical negligence claims, which is known as the “limitation” period. Clinical negligence claims must either be settled for compensation, or court proceedings be issued, within three years of the date of alleged negligence, or the date of knowledge of such negligence.

However, in cases involving children with brain damage or serious injuries, the time limit will be three years from the date of their 18th birthday.

There are occasions where the limitation period may be extended. Please get in touch to discuss your concerns, if you feel that this may apply to you. Call us on 01522 561020 or email wecanhelp@ringroselaw.co.uk



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