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Interim report on maternity care at Shrewsbury and Telford NHS Trust: a summary of findings

Posted: 18/12/2020

Maternity services at the Shrewsbury and Telford Hospital NHS Trust (SaTH) have come under significant scrutiny since the review into care began in 2016. This review was triggered not by mechanisms within the trust identifying a problem with its care, nor by external overseeing bodies, but by the efforts of bereaved parents who were not satisfied with how their concerns had been handled. These parents leave a lasting legacy for their children, Kate Stanton Davies and Pippa Griffiths, which will hopefully mean safer maternity care for other expectant mothers and unborn babies in the future.

The review is now so significant, with 1862 families involved, that the final report is not expected until 2021. At the heart of the investigation is the care given over the years between 2000 and 2019, though some limited earlier care is being considered.

Donna Ockenden and her team have been working hard to ensure that the voices of families who have had their children at the trust are heard, and at the same time making sure patient safety is prioritised and dealt with expeditiously. It is for this reason that before the review is concluded, an emerging findings and recommendations report was released on 10 December 2020 with immediate and essential actions itemised throughout.

Perhaps the most significant finding and learning point is the recommendation of an end to investigations, reviews and reports that do not lead to lasting meaningful change. Problems with care at Northwick Park in North London were identified between 2002 and 2005, with the death rates of women in pregnancy or within six weeks of birth well above the national average. The review into this anomaly showed that the trust had failed to learn from adverse incidents. A similar story was heard in 2015 when care at Morecambe Bay was investigated and findings also suggested that ‘normal’ childbirth (without intervention) was pursued at any cost and there was a repeated failure to investigate adverse incidents properly and to learn lessons. The story of the SaTH is, unfortunately, not a new one and the report confirms that had the recommendations of these previous investigations been implemented, along with the Saving Babies’ Lives Care Bundle Version Two (the success of which is explored in this article), lives would have been saved.

Key findings in the Ockenden review

The interim report goes into significant detail about the findings in the investigations, with considerable examples of poor care from those involved. It reaches 37 pages in length and highlights significant concerns in multiple different areas of care:

  • Compassion and kindness:
    • there were cases where women were blamed for their loss and this further compounded their grief; and
    • women and their families raised concerns about their care and were dismissed or not listened to at all.
  • Assessment of risk and place of birth:          
    • mothers were given insufficient information about their suitability for giving birth at a midwifery-led centre rather than an obstetric-led centre; and
    • there was insufficient information given on what would happen if they were birthing at a midwifery-led unit and a complication arose.
  • Managing complex care:
    • there was a failure to identify where a mother’s presentation was outside the norm and to refer for specialist input; and
    • high risk pregnancies were left under midwifery care or inappropriately managed by obstetricians in training.
  • Escalation of concerns:
    • midwives failed to recognise deterioration in a mother and to obtain specialist input.
  • Management of labour:
    • there were problems with how the baby’s heartbeat was listened to and the interpretation of results;
    • oxytocin, used to increase the frequency, strength and length of contractions, was used inappropriately and this continued consistently across the timeline being investigated by the inquiry.
  • Traumatic birth:
    • the incorrect use of oxytocin led to women needing to be assessed for instrumental delivery (delivery with ventouse or forceps);
    • repeated attempts at delivery with forceps, sometimes using excessive force with traumatic consequences; and
    • failing to abandon attempted vaginal delivery and moving to caesarean section at the appropriate and safest time.
  • A desire to keep caesarean section rates low (leading to the problems with the management of labour and traumatic births listed above):
    • caesarean section rates at the trust were consistently 8% to 12% lower than the national average over the years in question;
    • there was a perception that the essence of good maternity care was having a ‘normal’ birth; and
    • there was a lack of freedom to express a preference for caesarean section or to have any choice in the mode of the baby’s delivery.
  • Bereavement care:
    • inappropriate comments were made to family members after the loss of a baby;
    • there were several examples of mothers being made to feel responsible for their loss; and
    • very little follow-up support was offered or provided to bereaved parents.
  • Maternal deaths:
    • teams failed to work together to plan care for those who were at higher risk of complications;
    • there was a failure to use basic nursing practice to identify deteriorating patients; and
    • there are concerns about the standard of investigations into serious incidents such as maternal deaths, with no investigation at all in some circumstances, meaning no opportunity to learn.
  • Obstetric anaesthesia:
    • a failure to holistically consider the mother when providing obstetric anaesthesia;
    • there were errors in providing obstetric anaesthesia;
    • a lack of escalation to and involvement of senior anaesthetists; and
    • a failure to incorporate anaesthetists into incident investigations to ensure learning.

A very positive finding of the review was the quality of the neonatal care provided to those babies born in poor condition, with good communication and availability of senior staff cited as particular strengths.

Overall, these findings, however, set out a clear picture of a trust which had been functioning incorrectly over an extensive period of time. When presenting the report to the House of Commons, Nadine Dorries, Minister for Health, Suicide Prevention and Patient Safety, indicated that there is work underway on an early warning surveillance system, which - it is assumed - would draw on the available data to independently identify potential trusts in crisis.  

Implementing change

The report sets out 27 local actions for learning and seven immediate and essential actions arising from the above findings, which are to be implemented at the trust and are also aiming to improve services and patient safety at a national level. The most immediate changes identified are:

  • there needs to be better strategic oversight of the care provided;
  • women and their families must have a voice in the delivery of their care;
  • the different teams supporting mothers-to-be and newborn babies (midwives, obstetricians, obstetric anaesthetists and neonatologists) must be better integrated to provide a joined-up service;
  • complex pregnancies must be identified, risk assessed and correctly managed;
  • there must be continuing risk assessment throughout the pregnancy – if a mother-to-be begins her journey as a low risk patient, midwives must be on guard to identify changes that increase that risk and alter care accordingly;
  • the monitoring of babies’ heartbeats in labour needs to be significantly improved; and
  • women must be given the correct information to make informed choices about their mode of birth.


Donna Ockenden and her team have so far been working on this investigation for three years and within their investigations have identified significant numbers of mothers and babies who have died, or babies left with life-changing injuries, such as brain damage and cerebral palsy. The clinical negligence team at Penningtons Manches Cooper represents families involved in the review and knows from them, and from their extensive work in claims arising from maternity care, that the impact of harm at the time of birth has far-reaching consequences for families and communities.

Helen Hammond, senior associate in the clinical negligence team, comments: ”We welcome the findings of Donna Ockenden’s review so far and are pleased to see the release of the interim report to ensure that improvements in patient safety are not delayed by the scale of the investigation. We very much hope that the final report provides more detail or recommends further processes on a national level to ensure that there are triggers for independent reviews where there is a deterioration in maternity services, or an increase in poor outcomes for mothers and newborns, so that investigation does not have to be driven by bereaved parents who have already experienced significant trauma. The importance of accountability and transparency has, rightly, been considered in the interim report. A lasting legacy for those injured at the trust over the period of the review would be to ensure that we are never again confronted with a 19-year period where the same problems at a trust are allowed to continue with many innocent lives needlessly lost or shattered as a result.”

If you have any queries about pursuing a birth injury or maternity care claim, our specialist solicitors may be able to help. Please call us on 0800 328 9545, email or complete our online assessment form.

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