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In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).
Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its final report into cases of maternal and neonatal harm.
When this Review was commissioned in 2017, it concerned 23 families’ cases. Subsequently it has grown significantly, as families contacted the Review team with their concerns about maternity care and treatment at the Trust. The final report relates to 1,486 families, some with multiple clinical incidents, with the earliest case in 1973 and the latest in 2020.
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. This final report identifies hundreds of cases where the Trust failed to undertake serious incident investigations, with even cases of death not being examined appropriately. The review found that where investigations did take place they did not meet the expected standards at that time and failed to identify areas for improvement in care”
It outlines a shocking degree of avoidable harm in maternal and neonatal care. This includes cases of stillbirth, neonatal death, maternal death and other serious complications. The Review had initially published an interim report with findings and safety recommendations based on 250 cases in December 2020. The final report today includes a further 64 local actions for the Trust and 15 actions to improve care and safety in maternity services across England.
Over the coming days Patient Safety Learning will be looking in more detail at the findings of this report and its implications for patient safety, both in maternity care and wider healthcare. In this blog we set out our initial response, reflecting on some of the key patient safety issues that this highlights.
A recurring theme that comes up time and again in major patient safety scandals is that concerns raised by patients and family members are not acted on and, if harm occurs, they are left out of the investigation process. Related to this, patients’ complaints can often either be dismissed or not given a high enough priority to identify and address emerging patient safety issues.
One area where this report highlights similar concerns is in relation to patient complaints received by the maternity service at the Trust. Discussing the approach take to such complaints, it states:
“There is evidence that complaint responses lacked transparency and honesty, especially with regards to clinical care. The review team has identified families where care was sub-optimal, where different management would likely have made a difference to the outcome, however the complaint responses justified actions, delays and omissions in care. In addition, they often lacked compassion and in a number of responses it was implied that the woman herself was to blame.”
The report notes cases where families were not included in investigations where they should have been and a lack of compassion in Trust’s complaints process. They also highlight situations where complaints were dismissed, only for external investigations years later to identify failings which should have been evident at the time.
Having an effective complaints system provides an important opportunity to learn from incidents of unsafe care. Patients’ experiences can be used to help identify patient safety problems, ascertain the causes of these issues and put in place remedial measures to prevent them from recurring. It is positive to see that one of the report’s national actions is aimed at increasing patient and family involvement and in the design and development of maternity complaints processes nationally and at local level.
Taking a comprehensive approach to investigating patient safety incidents, identifying what went wrong and the actions needed to prevent a similar incident taking place in future, is vital to improving patient safety.
Unfortunately, a significant part of this report’s findings is centred on poor quality investigation processes. The Review’s assessment of the clinical governance processes and documents at the Trust revealed that investigations often fell below the standard expected. Concerningly, it states that:
“The reviews were often cursory, not multidisciplinary and did not identify the underlying systemic failings and some significant cases of concern were not investigated at all. In fact, the maternity governance team inappropriately downgraded serious incidents to a local investigation methodology in order to avoid external scrutiny, so that the true scale of serious incidents at the Trust went unknown until this review was undertaken.”
The report notes that both internal and external reports had pointed out the need to improve maternity investigations at the Trust, with a report by the Royal College of Obstetricians and Gynaecologists in July 2017 finding:
“… the Trust’s process of investigating SIs was complex and failed to adhere to recommended timescales; in one case reviewed by the RCOG team some 8 months after a stillbirth the report was still incomplete. The RCOG team also identified that the Trust’s internal team conducting the investigations was not appropriately resourced or trained in RCA methodology. It also identified that there was no culture of shared learning, that the RCAs often focused on the wrong issues, lacked system wide actions and focused instead on non-specific actions such as ‘share report widely’ and ‘learn from events’. There was no documentation that action plans were completed and recommendations often focused on individuals, rather than recommendations for system changes.”
One of the report’s key national actions to improve care and safety contains a number of provisions aimed at ensuring that future maternity investigations are meaningful for families and staff and that lessons are learned and implemented in a timely manner.
Good leadership plays a key role in shaping an organisations culture. Leaders can help to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this.
A key area of concern highlighted by this Review is the failure at a leadership level to identify and tackle patient safety issues. The Review stated that this was an problem at the highest levels of the organisation:
“The review has found the Trust leadership team up to Board level to be in a constant state of churn and change. Therefore it failed to foster a positive environment to support and encourage service improvement at all levels. In addition the Trust Board did not have oversight, or a full understanding of issues and concerns within the maternity service, resulting in a lack of strategic direction and effective change, nor the development of accountable implementation plans.”
The report also refers to leadership deficiencies at a clinical level and how in some cases this was interconnected with staff shortages, noting that an inadequate number of consultants for a maternity unit of the Trust’s size may have deterred midwives from escalating clinical concerns.
In its national actions the report states the need for Trust boards to have oversight and of the quality and performance of maternity services and contains specific provisions relating to improving clinical governance leadership in maternity services.
Too often in healthcare we see organisational cultures which seek to assign blame when things go wrong, making patient harm more likely to happen again. It is widely acknowledged that to ensure patient safety issues are consistently reported and acted on, staff need to feel safe to do so and work in an organisational culture that supports and promotes this.
The Review highlights a range of issues regarding culture at Shrewsbury and Telford Hospital NHS Trust. It states:
“The review team has also heard directly from staff that there was a culture of ‘them and us’ between the midwifery and obstetric staff, which engendered fear amongst midwives to escalate concerns to consultants. This demonstrates a lack of psychological safety in the workplace, and limited the ability of the service to make positive changes”
It also noted serious concerns, which we seem repeatedly in cases of serious patient safety failings, about staff not feeling able to speak up about safety issues. The Review team said they found evidence of staff being encouraged not to complain or raise awareness of poor practice within both personal and professional capacities, noting that:
“During the staff voices interviews some staff stated to the review team that there was a culture of bullying within the leadership team, and that this was not confined to the senior maternity management team but went across the Trust management structure.”
Without safe staffing levels, healthcare professionals are unable to deliver the quality care required to keeping patients safe from avoidable harm.
This is a major area of concern highlighted in this report. It points to significant staffing and training gaps within maternity services at the Trust and the negative impact that this had on its performance, noting that:
“Staff also cited suboptimal staffing levels and unsafe inpatient to staffing ratios to the review team, and said they often felt fearful and stressed at work due to poor staffing levels.”
In its actions to improve care and safety in maternity services across England, the report makes recommendations for change around both safe staffing and longer-term workforce planning and sustainability.
It specifically highlights the rollout of the new Midwifery Continuity of Carer model, aimed at improving safety in outcomes, and the need to pause this if Trust’s are unable to meet safe staffing requirements. As with any new innovations aimed at improving care, it is vital that we have the resources and staffing in place to support their implementation and robustly assess the impact of this on patient safety. Without this, the intended benefits and improvements of such changes will be lost.
Commenting on the publication of the report, its Chair, Donna Ockenden, acknowledged the systemic nature of the issues uncovered, stating:
“What is astounding is that for more than two decades these issues have not been challenged internally and the Trust was not held to account by external bodies. This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding.”
Over the last decade there have been multiple inquiries and reviews into serious patient safety failings in maternity care, with similar themes to the ones above being outlined being highlighted repeatedly. These reports are consistently followed with assurances that ‘lessons will be learned’ and that this will ‘never happen again’.
While the Government and NHS continue to respond to these issues in isolation, failing to tackle their underlying systemic causes, patients and their families will continue to suffer from a tragic loss and life and long-term effects of avoidable harm in healthcare. We need to fundamentally transform our approach to patient safety, making this a core purpose of health and social care.
 Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/investigation-reports/trust-investigations/ockenden-report-findings-conclusions-and-essential-actions-from-the-independent-review-of-maternity-services-at-the-shrewsbury-and-telford-hospital-nhs-trust-30-march-2022-r6505/
 Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Press Release: Final report of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust published, 30 March 2022. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2022/03/FINAL_PRESS_RELEASE_INDEPENDENT_MATERNITY_REVIEW_OF_MATERNITY_SERVICES_REPORT.pdf
 Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations from the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf