Maternity Care Failings Reported in Ockenden Interim Report
The Ockenden review into maternity services at Shrewsbury and Telford Hospital NHS Trust has this week published its report into the first 250 cases out of a total of the 1,832 which have been incorporated into its remit.
Not only the scale of the review, but the breadth and severity of many of its findings, are truly shocking.
After investigating the 250 cases, the review has identified concerns about practice and care in maternity services in the Trust in almost every aspect of mother and baby care.
Concerns have been identified in the following areas:
- Maternity care, where an 'unacceptable' lack of kindness and compassion was found where women could be blamed for the loss of their baby and where concerns of families could be ignored.
- Place of birth choices, where joint decision-making with the pregnant woman seemed to be lacking, leading to complications at the birth, and the death of either mother or baby.
- Clinical care which demonstrated a lack of competence and poor consultant oversight.
- Repeated failures to escalate concerns for further opinion and review
- Management of labour which demonstrated significant problems with the monitoring of fetal heart rate and examples where oxytocin for the control of contractions was used 'injudiciously'.
- Examples of inappropriate or poor use of forceps resulting in damage and death
- Reluctance to carry out caesarean sections
- Poor bereavement care including several instances where it was described as either 'inadequate or non-existent.'
- Poor obstetric anaesthesia practice
The report has consequently identified seven 'immediate and essential' actions intended to improve care and safety in maternity services' at the Trust, which it has also recommended be considered at maternity units across England. These include measures to improve safety, staff training, the management of complex pregnancy and the monitoring of fetal well-being as well as listening to the concerns of the women and their families.
The review will continue to investigate the remaining cases.
Earlier this year the government launched a review into the quality of maternity services at East Kent Hospitals University NHS Foundation Trust following reports of avoidable baby deaths at the Trust.
The government's Health and Social Care Committee has also recently launched a wider inquiry to assess the quality of maternity services across England.
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