Ockenden review: staff shortages and culture led to deaths
A review into almost 1,600 clinical incidents has identified failures to listen to families, failure to learn from clinical incidents and failure of multiple external bodies to act in improving maternity services, at the The Shrewsbury and Telford Hospital NHS Trust, over two decades.
The Independent Review of Maternity Services at the Trust, led by Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents where medical records and family consent was gained. The Ockenden review team spoke to the families involved about their care and examined medical records. In addition, current and former members of staff completed surveys, were interviewed and contacted the review team to talk confidentially. The review team also scrutinised vast volumes of documentation provided by the Trust.
The review found repeated failures in the quality of care and governance at the Trust throughout the last two decades, as well as failures from external bodies to effectively monitor the care provided. The final report has identified hundreds of cases where the Trust failed to undertake serious incident investigations, with even cases of death not being examined appropriately. The review found that where investigations did take place they did not meet the expected standards at that time and failed to identify areas for improvement in care.
These combined failings led to missed opportunities to learn, with families experiencing repeated serious incidents and harm throughout the period of the review.
The chair of the review, Donna Ockenden, commented: “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next. For example, ineffective monitoring of fetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.
“The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved. There was a tendency of the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths."
To read the final report, click here.