The final Ockenden report on maternity services at The Shrewsbury and Telford Hospital NHS Trust has highlighted problems with staff shortages, a lack of training, failures to investigate and learn from incidents, and a culture of not listening to families. So, what can we learn from these failures in maternity care and how can safety be improved?
The final report of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, led by Donna Ockenden, has identified failures to listen to families, failures to learn from clinical incidents and failures of multiple external bodies to act on improving maternity services at the Trust, over a period of two decades.
The review 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. This 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.
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