Summary of findings from the Ockenden Review of the Shewsbury and Telford Hospital NHS Trust

Introduction

The following provides a summary of the findings of the Ockenden Review of the Shewsbury and Telford Hospital NHS Trust which was released on 30th March 2022.

The review, led by Donna Ockenden, examined cases involving 1,486 families and 1,592 clinical incidents. The review found that 201 babies and nine mothers could or would have survived if they had received better care.

In summary, the review 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 findings echo those detailed within Morecambe Bay Investigation (2015) into maternal deaths, and the Savita Halappanavar Patient Safety investigation (2013), both of which HCI included as part of our research paper “The Healthcare System: Will We Ever Learn? Review of the common themes arising from UK and Ireland healthcare inquiries”.

Findings of the Ockenden Review include:

Patterns of repeated poor care

• Significant or major concerns in the maternity care provided that, if altered, might or would have resulted in a different outcome.
• Staff were overly confident in their ability to manage complex pregnancies and babies diagnosed with fetal abnormalities during pregnancy.
• Failure to follow national clinical guidelines.

Failure in Governance and Leadership

• Repeated failures to escalate concerns.
• A culture of ‘them and us’ between the midwifery and obstetric staff, which engendered fear among midwives to escalate concerns to consultants.
• A lack of action from senior clinicians following escalation.
• Poor working relationships.
• A lack of compassion expressed by staff.
• Medical staff rotas overstretched.
• A lack of clinical expertise to be available.
• The Trust leadership team up to board level was found to be in a constant state of churn and change. Therefore, it failed to foster a positive environment to support and encourage service improvement at all levels.
• The Trust board did not have oversight or a full understanding of issues and concerns within the maternity service, resulting in neither strategic direction and effective change, nor the development of accountable implementation plans.
• There was a culture of fear where staff were afraid to speak up about shortcomings in care.

Poor internal investigation into serious incidents

• Investigatory processes were not followed to a standard that would have been expected for the particular time the incident occurred. The reviews were often cursory, not multidisciplinary and did not identify the underlying systemic failings, and some significant cases of concern were not investigated at all. In fact, the maternity governance team inappropriately downgraded serious incidents to a local investigation methodology in order to avoid external scrutiny, so that the true scale of serious incidents at the trust went unknown until this review was undertaken.
• Lessons were not learned, mistakes in care were repeated, and the safety of mothers and babies was unnecessarily compromised as a result.

Poor overview by external bodies

• There were a number of external reviews carried out by external bodies, including local clinical commissioning groups and the Care Quality Commission, during the last decade. The review team is concerned that some of the findings from these reviews gave false reassurance about maternity services at the trust, despite repeated concerns being raised by families. It is the review team’s view that opportunities were lost to have improved maternity services at the trust sooner.

How can HCI Help?

National and international investigations into failings in the healthcare sector are continually ongoing. It was evident from HCI’s Research Paper The Healthcare System: Will We Ever Learn?, that time and again, similar system failings have led to similar patient outcomes, with the recommendations to address these outcomes often mirroring previous reports. It is imperative that providers of care reflect on the findings of these investigations to apply system-wide learning for the benefit of all service users.

If you require support in this area, HCI can conduct an independent audit of your service against the findings identified in investigations such as the Ockenden Review of the Shewsbury and Telford Hospital NHS Trust. This will help you implement the learnings from the inquiries, reduce potential risks and improve the overall quality and safety in your service.

Further Information

• Summary link: https://www.gov.uk/government/publications/final-report-of-the-ockenden-review/ockenden-review-summary-of-findings-conclusions-and-essential-actions#immediate-and-essential-actions-to-improve-care-and-safety-in-maternity-services-across-england
• Full report link: https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2022/03/FINAL_INDEPENDENT_MATERNITY_REVIEW_OF_MATERNITY_SERVICES_REPORT.pdf