After a series of incidents at Shrewsbury & Telford Hospital Trust, the long awaited Ockenden Report was published today. Over 1,500 clinical incidents including mothers and their babies who were seriously injured or died were investigated. This represents the biggest maternity care scandal in NHS history.
The Report identifies a pattern of repeated harm around poor care in complex cases; traumatic births with forceps; a culture of blaming mothers; the injudicious use of oxytocin to stimulate or increase contractions and a reluctance to conduct caesarean sections, in the mistaken belief that lower rates of caesarean section represented safer maternity care. The Shropshire caesarean section rate was the lowest in England, well below the national average and this was prioritised above the interests and safety of patients.
The Report identifies 15 areas for immediate and essential action around all aspects of maternity care, noting a need for improved staffing, training, multi-disciplinary working, governance and leadership and support for women and their families.
Our Medical Negligence Partner and Specialist Birth Injury Solicitor Michelle Armstrong shares her thoughts below:
“The Ockendon Report is a damning indictment on the state of maternity services. Not only does it identify significant failures of clinical care, there is evidence of repeated failures to investigate tragedies such as the death or serious injuries to mothers and their babies; failures in governance and leadership, in particular failure to take responsibility for and learn from mistakes; a toxic culture and even a trend for blaming mothers for failures in their care. I am encouraged that this comprehensive Report identifies a clear framework of required improvements and that this includes not just improvements in clinical care but recognition of the need to support the whole family, consider mental health and wellbeing of mothers and families and provide adequate bereavement support.
This Report makes incredibly difficult reading for anyone involved in or concerned about maternity care. As a former midwife, I know how passionate the majority of those involved in maternity care are about the safety of the women and families they care for. However, It is now time to learn from the tragic events in Shropshire which are likely repeated throughout the country and ensure that all maternity units have the resources to implement changes immediately.
Recognition has to be given to the bravery and resilience of the families whose commitment to holding the Trust to account led to this Report and we cannot allow their efforts to have been in vain.”
Michelle is our resident Birth Injury Specialist and works with mother’s and their families from all walks of life. She cuts through the jargon to bring you professional and sensitive advice when it matters most. If you would like an informal chat with Michelle, you can contact her on 01228 552222 and firstname.lastname@example.org