The final report of Donna Ockenden’s review of maternity services at the Trust has been published. The review examined cases involving 1,486 families between 2000 and 2019 and investigated 1,592 clinical incidents.

It found repeated failures in the quality of care and governance at the Trust as well as failures of monitoring by external bodies. In hundreds of cases the Trust failed to undertake serious incident investigations (SIIs) and, where they did take place, they were not of the appropriate standard and failed to identify areas for improvement. These failings meant that opportunities to learn were missed and serious incidents (SIs) and harm continued to occur. Reasons for the failures included: insufficient staff; lack of ongoing training; lack of investigation and governance; a culture of not listening to families and a tendency to blame mothers for poor outcomes. There were 295 avoidable baby deaths or brain damage cases and nine maternal deaths as a result of poor care.

The review concluded that systemic change is needed both locally and nationally and that awareness of and accountability for values and standards should stretch from “ward to board”. Over 60 ‘Local Actions for Learning’ were directed to the Trust with 15 additional ‘Immediate and Essential Actions’ (IEAs) for all maternity services in England.

Immediate and Essential Actions

The IEAs cover ten key areas:

1. Financing a safe maternity workforce. A multi-year investment plan is required to provide a well-staffed workforce, with nationally agreed and adhered-to minimum staffing levels.
2. Essential action on training. This includes multi-disciplinary training, refreshers and protected training time.
3. Maintaining a clear escalation and mitigation policy when staffing levels are not met. Escalation should go to the senior management team, board, patient safety champion and local maternity system. The Midwifery Continuity of Carer model must be suspended across all Trusts unless they can demonstrate staffing meets minimum requirements.
4. Essential roles for Trust boards in oversight of their maternity services. A process of regular reports and reviews is required to ensure implementation of improvement plans. Every Trust should have a patient safety specialist dedicated to maternity.
5. Meaningful incident investigations with family and staff engagement and practice changes introduced in a timely manner. Lessons from clinical incidents must form the basis of a multi-disciplinary training plan. Changes in clinical practice must be evidenced by six months post-incident.
6. There must be mandatory joint learning across all care settings when a mother dies.
7. Care of mothers with complex and multiple pregnancies. Care must be provided by specialists in this area and, if necessary, sought elsewhere.
8. Ensuring the recommendations from the 2019 Neonatal Critical Care Review are introduced at pace.
9. Improving post-natal care for the unwell mother. A system must be developed to ensure consultant review of all post-natal re-admissions.
10. Care of bereaved families. Bereavement services must be available seven days a week, a system in place for follow-up appointments and staff trained to take post-mortem consent.

What this means for you

The ‘golden thread’ of good governance runs through many of the IEAs. Lack of good governance aided and abetted by the “constant churn” of leaders at the Trust appears at the heart of many of the failures identified.

Transparency and candour when things go wrong, with ward-to-board quality assurance based on a ‘no blame culture’, will be key to ensuring what happened at Shrewsbury and Telford Hospital NHS Trust is never repeated. Trusts should review their governance procedures and policies, particularly around candour, SI investigation and escalation and mitigation when agreed staffing levels are not met, to ensure that they are robust and fully fit for purpose. Ensuring post-SI changes in clinical practice are not only implemented but reviewed by the post-incident six month date and evidenced, is particularly crucial. Training should be multi-disciplinary with lessons from clinical incidents forming the basis of the training plan. It seems clear that training with those you work with is not only logical but safety critical.

Trusts may also experience closer scrutiny from the Care Quality Commission, given the concern expressed in the report that some findings gave false reassurance and contributed to learning opportunities being missed.

How Capsticks can help

Capsticks is a national leader in representing both NHS and private healthcare providers as well as medical malpractice insurers. Our dedicated team is renowned for advising on the defence and resolution of clinical negligence claims, inquests, management of complaints and serious incident investigations/inquires, and providing an innovative outsourcing service for claims and inquests handling.

We will be running a webinar to consider the report and next steps in more detail. Please register your interest here and we will confirm the date and other arrangements in course.

If you have any queries on the topics discussed in this insight, or the impact on your organisation, please contact Philip Hatherall, Majid Hassan or Charlotte Rathbone.