Letter to the Secretary of State for Health and Social Care from Donna Ockenden:
Dear Secretary of State
I publish the final report of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, at a time when the NHS continues to face significant challenges arising from the coronavirus (COVID-19) pandemic. In the 2 years of this pandemic since early 2020, the NHS and its staff have had to be ever more innovative in the ways services are delivered to ensure the provision of high-quality care to patients.
NHS staff – including maternity teams who have worked throughout this pandemic – are exhausted. We have seen so many frontline NHS staff go above and beyond the call of duty to support and care for their patients in these truly extraordinary times. Our NHS is rightly held in high regard by so many for the lives it saves and the care it provides.
However, this final report of the Independent Maternity Review of maternity services at the Shrewsbury and Telford Hospital 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.
This review owes its origins to Kate Stanton Davies, and her parents Rhiannon Davies and Richard Stanton; and to Pippa Griffiths, and her parents Kayleigh and Colin Griffiths. Kate’s and Pippa’s parents have shown an unrelenting commitment to ensuring their daughters’ short lives make a difference to the safety of maternity care.
It was through their efforts that your predecessor, the former Secretary of State for Health Jeremy Hunt, requested this independent review. When it commenced, this review was of 23 families’ cases, but it grew to include reviews of nearly 1,500 families, whose experiences occurred predominantly between 2000 and 2019.
This final report follows on from our first report, which was published in December 2020. In the first report, we outlined the local actions for learning (LAfL) and immediate and essential actions (IEAs) to be implemented at the trust and across the wider maternity system in England.
This second report builds upon the first report in that all the LAfL and IEAs within that report remain important and must be progressed. For this second report, my independent maternity review team have identified a number of new themes that we believe must now be shared across all maternity services in England as a matter of urgency to bring about positive and essential change.
Our LAfL for the trust and IEAs must be implemented by the Shrewsbury and Telford Hospital NHS Trust with the IEAs considered by all trusts across England in a timely manner.
Since the publication of our first report, the government has introduced a range of measures and invested very significantly in supporting maternity services across the country. This focus and funding is a significant stride in the right direction. Much of this funding is for workforce expansion. NHS Providers, as cited in the recent Select Committee report has estimated the cost of full expansion of the maternity services workforce to be £200 to £250 million. We endorse and support this view.
In the last year since our first report was published, we have seen significant pressures in maternity services in the recruitment and retention of midwives and obstetricians. Workforce planning, reducing attrition of maternity staff, and providing the required funding for a sustainable and safe maternity workforce is essential. Continuing progress on funding the maternity multi-professional workforce requirements now and into the future will mean that we can continue to ensure the safety of mothers and their babies, and meet the government’s key commitment to halve the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries in babies occurring soon or after birth by 2025.
In our first report, we wanted to ensure that families’ voices were central as, for far too long, women and families who accessed maternity care at the trust were denied the opportunity to voice their concerns about the quality of care they had received. Many hundreds of families who received maternity care at the trust have told us of experiencing life-changing tragedies that have caused untold pain and distress. In order to ensure families’ voices are heard, listened to and acted upon within maternity services, the NHS will need to continue progress on the role of the independent senior advocate role within maternity services that was an IEA in our first report.
Secretary of State, through our work to date we have recognised a critical need for timely and independent reviews of serious maternity incidents to ensure lessons are learned and changes implemented effectively. We note and endorse the creation of a Special Health Authority to oversee maternity investigations, taking over the work of the Healthcare Safety Investigation Branch. We fully support your view that the provision of “independent, standardised and family focussed investigations of maternity cases that provide families with answers” is essential.
We further urge that there must be a timeliness to this work since delay in introducing change and learning leads to the risk of repeated incidents, as we saw at the Shrewsbury and Telford Hospital NHS Trust. We would expect that learning and service change from maternity incidents be introduced into clinical practice within 6 months of the incident occurring, and that all investigations are independently chaired.
Finally, and importantly, Secretary of State, we state that the Department of Health and Social Care (DHSC) and NHS England and Improvement (NHSEI) must now commission a working group – independent of the Maternity Transformation Programme – that has joint Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG) leadership to make plans to guide the Maternity Transformation Programme around implementation of these IEAs and the recommendations of other reports currently being prepared.
Thank you, Secretary of State, for your ongoing support.
Yours sincerely,
Donna Ockenden
Chair of the Independent Maternity Review
Further information on the report can be found by visiting – Ockenden review: summary of findings, conclusions and essential actions – GOV.UK (www.gov.uk)
Responding to the publication of the final report of the Independent Review of Maternity Services – the ‘Ockenden Report’ – Louise Barnett, Chief Executive at The Shrewsbury and Telford Hospital NHS Trust said:
“Today’s report is deeply distressing, and, on behalf of all at The Trust I offer our wholehearted apologies for the pain and distress that has been caused.
“We recognise the strength and determination shown by the women and families involved and take full responsibility for our failings as a Trust.
“This brings with it a duty to ensure that the care we provide today and in the future is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.
“We have had the first report from December 2020, which set out a wide range of actions for us, and other Trusts to deliver. Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden Report, and we are extremely grateful to Mrs Ockenden and her team for all they have done to help guide these essential improvements.
“We know that we still have much more to do to ensure we deliver the highest possible standard of care to the women and families we care for.
“Now that we have received the final report, we will approach the requirements with the focus and resolve we brought to the initial recommendations.
“We owe it to those families we failed, those we care for today and in the future, and our valued colleagues providing that care, to continue to make the necessary improvements so we are delivering the best possible care for the communities we serve.”
Contains public sector information licensed under the Open Government Licence v3.0.
