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Last night’s BBC Panorama programme ‘Maternity Scandal: Fighting for the Truth‘ reported on the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust. The BBC aired the programme ahead of next month’s Ockenden report into investigations of newborn, infant and maternal harm at the Trust.
Panorama examined why so many maternity failures were allowed to happen for so long. Initially, families collected 23 cases, dating back to 2000, including stillbirths, neonatal deaths, maternal deaths, and babies born with brain injuries.
Appalled by what they found, the families wrote to the then health secretary Jeremy Hunt in December 2016, asking him to order an investigation. He agreed, and in May 2017, senior midwife Donna Ockenden was appointed to lead the review.
Ms Ockenden told Panorama last night: “These are among the most serious cases that we have seen in our careers. The likelihood would be that when one tried to put together the full jigsaw, there would be other cases, but we didn’t know that at the outset.”
As BBC reporter Michael Buchanan highlights, the number of families approaching Donna Ockenden about maternity failures at Shrewsbury and Telford Hospital NHS Trust has escalated rapidly. What was initially an investigation into 23 cases has resulted in the review team examining the care 1,872 families received, with an additional 7 families more recently stepping forward.
An interim report published in December 2020 noted that the Trust failed to investigate after something went wrong or carried out its own inquiry in many cases. Panorama discovered the Trust developed its own investigation system – a High-Risk Case Review.
However, as well as being a system not used in any other NHS organisation, the system sat outside any national framework that has been used to help learn lessons from incidents. This meant that fewer incidents were reported to NHS regulators, limiting the opportunity to learn lessons.
Discussing the initial findings of her inquiry, Donna Ockenden told Panorama:
“There were cases where an earlier recourse to caesarean section rather than a persistence towards a normal delivery may well have led to a better outcome for mother or baby or both. Low caesarean section rates were a prize.”
The Ockenden interim report found 9 areas where the Trust had repeatedly failed. As well as low caesarean rates, they highlighted the excessive use of forceps, the repeated misuse of a labour inducing drug, a failure to escalate concerns to senior clinicians and a lack of compassion and kindness in delivering care.
Shockingly, we heard accounts of healthcare professionals telling parents quite clearly that what had happened was their fault. Fathers were made to feel they should have been able to stand up for their wives and partners. Donna Ockenden poignantly says: “…it isn’t your guilt to carry.”
Bernie Bentick, a retired Consultant Obstetrician and Gynaecologist for nearly 30 years at Shrewsbury and Telford Trust, said:
“Because resources were scarce, there was a tendency to blame individuals for not following guidelines rather than look at the underlying factors which may have led to a particular problem, and in particular staffing levels in the midwifery department. These were frequently not enough.”
“Last night’s Panorama programme provided an eye-opening investigation into the maternity failures at Shrewsbury and Telford Hospital NHS Trust.’ It was devastating and harrowing but a necessary watch.
“We saw a culture of poor maternity care, incompetent management, and a lack of understanding and sensitivity towards bereaved parents who, having just endured the trauma of stillbirth, were put into rooms with healthy babies. What was clear is that often there was just a simple failure to listen and learn with many opportunities missed to avoid harm to both mothers and babies.
“The interim Ockenden report led to a nearly £100 million investment in maternity services in England, but there are clearly resourcing issues. There needs to be a vital investment in safety to improve outcomes and boost learning opportunities to reduce serious harm in the first place.
“The publication of Donna Ockenden’s final report next month will be a watershed moment in the history of the NHS, although perhaps little consolation for those poor families who’ve been deeply affected.
“I am humbled by the bravery of parents, who, having suffered unimaginable loss, shared their stories with such openness in the hope that their tireless fight for justice will benefit others.”
The Panorama programme ‘Maternity Scandal: Fighting for the Truth’ is available to watch on BBC iPlayer.
If you have any concerns about the treatment you and your baby have received in a hospital or any other healthcare setting, Novum Law’s team of specialist medical negligence solicitors can help on a no-win, no fee basis. To find out more information, contact us on Freephone: 0800 884 0777 or email: firstname.lastname@example.org.