Skip to content Skip to main menu Skip to utility menu

Chief Executive’s Message – Friday 1 April

April 1, 2022

The final report of The Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, led by Donna Ockenden was published on 30 March 2022. The review examined cases involving 1486 families between 2000 and 2019. The review team spoke to families involved about their care, examined medical records and conducted surveys and interviews with current and former members of staff.

The review found repeated failures in the quality of care and governance at the Trust throughout the last two decades, as well as failures from external bodies to effectively monitor the care provided. There were missed opportunities to learn, with families experiencing repeated serious incidents and harm throughout the period of the review.

More than 60 local actions for learning were identified along with immediate and essential actions for all maternity services cover ten key areas:

  1. Financing a safe maternity workforce
  2. Essential action on training
  3. Maintaining a clear escalation and mitigation policy when staffing levels are not met
  4. Essential roles for Boards in oversight of their maternity services
  5. Meaningful incident investigations, with family and staff engagement, and practice changes introduced in a timely manner
  6. Mandatory joint learning across all care settings when a mother dies
  7. Care of mothers with complex and multiple pregnancies
  8. Introduction at pace of the recommendations from the 2019 Neonatal Critical Care Review
  9. Improving postnatal care for unwell mothers
  10. Care of bereaved families

I am very conscious of the wide variety of concerns and views flying around about this review.  There is a big debate about what caused the issues, which to me seem to be a combination of two things: the Trust’s interpretation of a long standing national strategy to increase the percentage of births that were delivered “normally”, as opposed to caesarean section and poor quality governance and learning within the service at Shrewsbury & Telford Trust.

We must and already are in the process of reflecting on and acting on each of these two key matters as the findings are not unique to just one Trust.  Maternity and neonatal services in our Trust are subject to intensive oversight by the Board on a monthly basis.  Significant time and effort is being put in my a diverse and committed leadership team throughout maternity and neonatal services to ensure that we:

  • Have strong quality governance in place and learn from when things go right as well as when things go wrong
  • Listen to all staff’s views about how the culture, morale and practice within our services can be improved
  • Deliver services which are culturally sensitive and therefore provide needs led, person centred care

I am conscious also about the impact the Ockenden report will have on the clinical and support staff in the service, as well as the impact it will have on those who may be considering joining the professions of midwifery or obstetrics.  Whilst well intended and ultimately necessary, the publicity these reviews often get can drive an unintended consequence of lowering morale in a service already under pressure.  We must all look out for the welfare and wellbeing of our colleagues in maternity and neonates over the coming months, as they work through the challenges they face day to day, whilst at the same time improving the quality of care they provide in a very public glare.

Have a good week.