Ockenden Review Calls for Immediate Action in Maternity Units

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Shrewsbury and Telford Hospital NHS Trust has been told to implement “essential and immediate actions” following concerns over patient safety in its maternity services.

An independent review into the Trust was commissioned by the government following the tragic case of Kate Stanton-Davies, who died just 6 hours after her birth while in the care of the Trust in 2009.

Our National Head of Injury, Ian Cohen, represented her devastated parents in their fight for justice and says that the initial findings are a small step in the right direction.

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Ockenden Report Recommendations

The Ockenden report into Shrewsbury and Telford Hospital NHS Trust puts forward a number of recommendations and has called for a greater emphasis on training, communication and risk management. Donna Ockenden has appealed for these recommendations to be implemented at The Shrewsbury and Telford Hospital NHS Trust as soon as practically possible and that they should be given thorough consideration in all maternity units across England.

These recommendations cover 7 key areas. They are:

safety in maternity units across England must be improved with partnerships between Trusts and local networks. Neighbouring Trusts must work together so that local investigations into Serious Incidents have regional and Local Maternity System (LMS) oversight.

the creation of an independent senior advocate role, which reports to the Trust and the LMS boardThe advocate must be available to families at follow up meetings with medical staff where concerns about maternity or neonatal care are raised, especially where there has been an adverse outcome. CQC inspections must include assessments of whether women’s voices are truly heard by the maternity service, with involvement of the Maternity Voice Partnership.

evidencing regular training which must be validated by the LMS 3 times a year, twice daily consultant led ward rounds and ring fencing training funding for maternity staff.

There must be clear pathways for managing women with complex pregnancies. These pathways should be developed by agreeing the criteria for discussing those cases, or referring them to a Maternal Medicine Specialist Centre.

Staff must make sure that women are risk assessed at every contact through their pregnancy.

there must be a dedicated Lead Midwife and Lead Obstetrician with expertise to focus on and champion best practice in fetal monitoring.

all Trusts must make sure that women have access to accurate information so they can make an informed choice about their place of birth, mode of birth and choice about caesarean deliveries.

Ian Cohen, National Head of Injury at Simpson Millar, commented: “The families involved in this review have waited years for answers, and for justice to be done.

“While the initial recommendations appear to address some of the many, many concerns highlighted as part of the cases under review, the reality is that there is no one holding failing Trusts across the country to account when it comes to implementing such change.

“Until that happens, I’m afraid the struggle and heartache of so many bereaved parents has simply not been recognised, and they will take limited comfort that lessons have truly been learnt.

“As the review into the 1862 cases continues, we would urge the review committee to do more to ensure that all trusts publish their plans and a tangible timeline to provide much needed reassurance – both to those who have already suffered, as well as expectant mothers.”

You can read the full report here.

  • "As identified in the report, there is a desperate need for a ‘critical oversight’ of patient safety in maternity units nationwide. Surely, we are therefore beyond simply ‘imploring’ to their sense of duty?"

    Ian Cohen

    National Head of Injury at Simpson Millar

Why Was the Review Set Up?

An independent review into Shrewsbury and Telford Hospital NHS Trust’s maternity services was set up by the then-Health Secretary Jeremy Hunt three years ago, after concerns were raised by the parents of several babies who died shortly after birth, including the parents of Kate Stanton-Davies.

The review was initially asked to look into 23 cases, but hundreds more reports of avoidable baby deaths, brain damage and stillbirths involving the Trust emerged, leading to almost 2,000 cases being investigated.

This is an emerging findings report, which has considered the experiences of 250 of the 1,862 families identified in the Ockenden Review.

If you used Shrewsbury and Telford Hospital NHS Trust’s maternity services and think your care was negligent, please get in touch with one of our Medical Negligence Solicitors. There’s no obligation to make a claim, and were happy to have an informal chat about your situation.

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