The Ockenden Report into maternity services at Shrewsbury & Telford NHS Trust has been published today, revealing shocking details of the investigation.
Following a review of almost 1600 cases, occurring over a period of around twenty years from 2000 to 2019, the report has identified that more than 200 babies could have survived had maternity services at the Trust provided better care. In addition, poor-quality care has been linked to babies suffering severe, life-changing brain injuries.
The report has found instances not only of failures in care, but also failures to investigate where mistakes had been made, leading to a failure to learn from those mistakes. As a result, repeated incidents continued to occur.
Specific reference was made to failures relating to fetal monitoring and ‘a culture or reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth.’
Identifying root causes as a shortage of staff, a lack of training and ineffective governance, the report includes over sixty ‘local actions for learning’ plus fifteen ‘immediate and essential actions’ for all maternity services in England.
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