Report Identifies 27 Actions For Shrewsbury and Telford Hospital NHS Trust And Seven Essential Actions For NHS Nationally

Specialist lawyers representing families affected by one of the biggest maternity scandals in history have backed calls for urgent action to improve care.

The long-awaited Ockenden Review report into maternity care at Shrewsbury and Telford hospitals has today been published, identifying 34 areas where maternity care should be improved. 

This includes 27 ‘actions for learning’ by Shrewsbury and Telford Hospital NHS Trust and seven ‘immediate and essential actions’ not only for the Trust but for all maternity services across England. 

Law firm Irwin Mitchell is representing a number of parents who say they have suffered as a result of failings in maternity care at Shrewsbury and Telford Hospital NHS Trust, stretching back decades. Experts at Irwin Mitchell have also contributed to the Health Committee’s Maternity Safety Call for Evidence.

The Ockenden review is investigating more than 1,800 cases involving the Trust. It has published initial findings based on 250 cases of concern, including the original 23, which triggered the probe. 

Former senior midwife, Donna Ockenden, the chair of the independent review, said that the 34 actions are “must dos that need to be implemented now at pace.” 

Expert Opinion

“Today is bittersweet for the families; as while the scale of problems involving maternity services at Shrewsbury and Telford vindicate their concerns they also lay bare the terrible consequences of what happened.

“Patient safety should be the fundamental priority in all care. We’re deeply concerned by the report’s findings in particular that issues were seemingly allowed to manifest themselves for years because of continuing care problems and lessons not being learned as well as some families’ concerns not being listened to.

“Sadly other maternity scandals such as Morecambe Bay and East Kent Hospitals would indicate that what happened at Shrewsbury and Telford wasn’t an isolated problem which we believe the review has acknowledged in its national recommendations.

“Too often in the past we’ve seen reviews and investigations into hospital care make recommendations which have taken years to implement.

“As also identified by the Ockenden Review, we reiterate our call for decisive and meaningful action to be taken to address the issues identified in this report.

“While sadly it’s too late for the thousands of people whose lives have been devastated the findings are a clear indication that things have to change both locally and nationally.

“We’ll continue to support the families we represent to provide them with all of the answers they deserve while continuing to campaign for improvements in maternity care.” Tim Annett - Partner

The initial findings report covered cases between 2000 and 2018. As well as looking into 250 cases the review team also spoke with another 800 families. 

The report said improvements for Shrewsbury and Telford Hospital NHS Trust included more experienced doctors having an oversight of maternity care, improved training and the appointment of lead obstetricians and midwives with expertise in monitoring the heart rates of babies.

There should also be ongoing risk assessments of women and families should have more input into serious incident investigations. 

The seven immediate and essential actions are: 

• Health trusts working more closely together to investigate serious incidents and sharing lessons to enhance safety.
• Every trust should have a senior advocate role to listen to families and ensure families’ voices are represented at board level.
• Better training for staff and staff should work together. There must be twice daily consultant-led ward rounds seven days a week, in the day and at night.
• The creation of specialist regional centres to help manage complex pregnancies must be “an urgent national priority”. 
• All women should be formally risk assessed at every antenatal appointment.
• All maternity services should appoint a dedicated lead midwife and lead obstetrician with expertise in monitoring of babies.

An investigation was ordered into baby deaths at Shrewsbury and Telford Hospital NHS Trust in 2017 by then Health Secretary Jeremy Hunt.

The independent review was initially to look into 23 cases. That was expanded to more than 270 in 2019.

Earlier this year the review announced it was looking into 1,170 cases stretching back 40 years. In July this was extended again to cover 1,862 cases.

A leaked report into the inquiry last year revealed a catalogue of concerns and that dozens of mums and babies were believed to have died or been left disabled because of poor care at the Trust.

West Mercia Police is also investigating alleged failings and whether they are grounds for a criminal case.

Find out more about our expertise in supporting families affected by birth injury and maternity care at our dedicated Shrewsbury and Telford hospitals section. Alternatively to speak to an expert contact us or call 0370 1500 100.