Maternity scandal report - urgent changes needed

Urgent changes are needed in all hospitals in England to prevent avoidable baby deaths, stillbirths and neonatal brain damage, according to the report into one of the biggest scandals in the history of the NHS.

It reveals a series of serious failures at Shrewsbury & Telford hospitals (SaTH) that led to the injuries and deaths of mothers and babies from 2000 – 2019, including:

• A lethal reluctance to conduct caesarean sections
• A tendency to blame mothers for problems
• Failure to handle complex cases
• Lack of consultant oversight
• A “deeply worrying lack of kindness and compassion”

In total, the independent review has found 1,862 serious incidents including hundreds of baby deaths and an “unusually high” number of maternal deaths - 13 women  died giving birth between 2000 and 2019 with two other deaths before 2000. A clinical review of 250 of the cases prompted midwifery expert Donna Ockenden, leading the review, to outline an emerging findings report so that action can be taken immediately before the full report is carried out. Once completed, the review is likely to be the largest in NHS history.

The interim report details 27 local actions for learning and seven immediate and essential actions for all maternity services “to be implemented now and at pace”, including:

• Formal risk assessment at every antenatal contact
• Twice-daily consultant-led maternity ward rounds
• Woman and family advocates on the board of every NHS trust
• The appointment of dedicated lead midwives and obstetricians

“We owe it to the 1,862 families who are contributing to this review to bring about rapid positive and sustainable change across the maternity services at SaTH,” says the report.

Other recommendations include ringfenced funding for maternity training, greater oversight of maternity care by senior doctors and the development of regional specialists in maternal medicine. The full report can be found here.

Ockenden said: “We implore maternity services across England to carefully consider this first report and to make ambitious plans to ensure timely implementation of these local actions for learning and immediate and essential actions takes place.”

The Ockenden review was originally ordered in 2017 by Jeremy Hunt, then health secretary, when the families of two babies, Kate Stanton-Davies and Pippa Griffiths, who died under the trust’s care, raised concerns about their cases and those of 21 other families.

Health minister responsible for patient safety and maternity, Nadine Dorries, said: “I expect the trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families.

“This government is utterly committed to patient safety, eradicating avoidable harms and making the NHS the safest place in the world to give birth. We will work closely with NHS England and Improvement, as well as Shrewsbury and Telford hospital NHS trust to consider next steps.”

Louise Barnett, SaTH’s chief executive, said it would implement all the recommendations in full: “On behalf of the whole trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our trust.

“I can assure the women and families who use our service that if they raise any concerns about their care they will be listened to and action will be taken.”