Ockenden Review 'must be acted upon immediately' say Royal Colleges
The Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have called for action following the publication of a damning report on failures at Shrewsbury and Telford NHS Trust.
Responding to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden, the Royal Colleges said that strong leadership, challenging poor workplace culture, and ring-fencing maternity funding will be key to improving safety.
The RCOG and RCM welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again.
The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK.
Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour.
“All recent national reports have identified that staff struggle with a lack of resources and capacity to provide best care. Excellent services mean staff are empowered to work to the best of their abilities in a system that values and supports them, in order to provide the best possible care for women and their families.
“We owe it to all families affected by these tragedies to fully consider these recommendations, translate learning into practice and join up current programmes and resources within the maternity system to help the Government deliver on its manifesto promise to make the UK the best place in the world to give birth.”
RCM Chief Executive Gill Walton said: “We are committed to improving safety within all maternity services. The recommendations and actions contained in this report are key to ensuring lessons from these devastating tragedies are learned – and acted upon. Teams delivering care must be better at working together. I cannot emphasise enough the importance of respectful team working to build a supportive workplace culture. That starts with teams training together, not simply staying in their professional corners. That sense of partnership needs to extend beyond Trust and Board boundaries too. It is crucial that those who are struggling can learn from those services doing well to improve safety.
“Funding for training is precious and must be used for its intended purpose. We fully support the review’s recommendation that any externally allocated training funds which have been earmarked for maternity services must be ring-fenced for their intended purpose.”
The development of maternal medicine specialist centres within regions, as recommended by the review, is strongly supported by both Colleges. The RCM and RCOG are already spearheading a number of projects and programmes which will support this aim. This includes a new digital tool for use by maternity staff and pregnant women to reduce preterm birth and stillbirths which is currently under development with pregnancy charity Tommy’s, and a new assessment tool to identify and mitigate risk in pregnant women.
Failures in interpretation and action in response to fetal monitoring are a leading contributory factor in many cases of avoidable harm. The RCM and the RCOG are advocating for a standardised national programme, delivered locally by trained experts, that would see high quality clinical simulation combined with structured organisational learning interventions, to improve systems, culture and behaviour supportive of appropriate fetal monitoring interpretation and response.
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