Nottingham Maternity: Donna Ockenden to Chair Independent Inquiry29 Jun 2022 | Stephanie Prior
An interim report on the state of maternity services at Nottingham University Hospitals NHS Trust has just been released. However, after around 100 women wrote to Health Secretary Sajid Javid, criticising the report, Donna Ockenden was appointed to head up a separate, independent investigation into the Trust.
A senior midwife with more than 30 years of experience, Donna Ockenden was Chair of the England Royal College of Midwives between 2006 and 2014. She more recently and more famously, led the Shrewsbury and Telford NHS Trust investigation into deaths of over 200 babies who died due to failings in maternity care there. Ockenden will now focus her experience on the more than 500 cases of women and babies who suffered harm while ostensibly under the care of the Nottingham University Hospitals NHS Trust.
In a letter from the Chief Operating Officer of NHS England and NHS Improvement, affected families were told, ‘I can confirm that Donna Ockenden has agreed to chair the new Review and we will work with her to develop a new Terms of Reference that reflects the need to drive urgent improvements to local maternity care and the need to deliver actionable recommendations that can be implemented as quickly as possible’.
Interim report: review of incidents at Nottingham University Hospitals NHS Trust
So, what were the findings of the interim report and why was it rejected, to be replaced by a new Ockenden review? Released in April 2022 the interim report rated the Nottingham University Hospitals maternity service as ‘inadequate’, blighted with cultural and staffing issues. Failings included poor leadership and a culture resistant to learning lessons. Other concerns included lack of training, insufficient risk assessment of patients, inadequate medicine management, a culture of bullying behaviour and an overall lack of respect.
Despite being critical of Nottingham’s maternity services, the review was rejected by campaigners due to its lack of independence and apparent inadequate investigative remit. And although the Chief Executive of the Trust apologised for the problems identified by the report and offered reassurances that ‘significant changes’ were being made to address the issues, including ‘hiring and training more midwives and introducing digital maternity records’, local women remain to be convinced. Indeed, it has been reported that families who have conceived again moved home from out of the area, so that their pregnancies would not fall under the remit of the Nottingham Trust.
In response to the Ockenden appointment, the NHS England Chief Operating Officer said, ‘after careful consideration and in light of concerns […] that the current (interim) review is not fit for purpose, we have taken the decision to ask the current review team to conclude all of their work by Friday 10 June 2022. We will be asking the new national review team to begin afresh drawing a line under the work undertaken to date by the current local review team’.
National attention and calls for a public inquiry
The problems in the Nottingham maternity services first came to national attention in 2021 following a Channel 4 News and Independent report that between 2012 and 2020, 46 babies suffered brain damage and 19 were stillborn in the Trust. In subsequent investigations, it was found that relevant medical notes were missing or never made, and others were completely inaccurate. Furthermore, several deaths were never investigated, and outcomes of those that were actually completed, were minimised by hospital management. To date more than £91million in damages has been paid out to families.
Many of the affected families have spoken out about their experiences and have called for this external review so that the truth is uncovered. Ms Ockenden said that ‘clearly something is very, very wrong at the Trust’ and her priority is to listen to the families.
The issues in the maternity services have been known for some time. In 2018, doctors and midwives sent a letter to the Trust board stating that inadequate staffing levels were impacting patient safety. As recently as March 2022, it was determined that the maternity service did not have enough staff to care for women safely and since then warnings have been issued over safe care and treatment, especially pertaining to clinical observations and triaging of new patients. The Care Quality Commission said, ‘It’s disappointing that despite several inspections […] serious problems remain’.
Families formally respond to Ockenden’s appointment
The families affected by the failings of the Trust released a statement, ‘We cannot describe the immense sense of relief that we feel at the news that Donna Ockenden has been appointed. We are confident that she will conduct a robust review to ensure the scale of failings […] are recognised and essential improvements are made. Donna Ockenden’s appointment is a significant step towards restoring confidence in Nottingham maternity services’.
A change in the law?
Under the Coroner and Justice Act 2009, in England and Wales, a stillborn child is not classified as a ‘deceased person’, so an inquest into their death does not need to be held. Campaigners believe that if a coroner’s inquest had been held into other stillborn children at the Trust, the institutional problems would have been identified earlier and changes initiated. Perhaps it is indeed time to consider a change in the law.
Following the publication of the Ockenden Report Stephanie Prior speaks to Sky News of her concerns of other NHS Trust maternity units.
Stephanie Prior’s maternity care concerns
Stephanie Prior was interviewed by Sky News and Times radio following the investigations. Stephanie, who refers to the families her team has represented since the 20-year investigation period ended, says ‘lessons haven’t been learned, which doesn’t help the families affected later on in the timeline… I don’t think the issues identified within that report are unique to Shrewsbury and Telford Hospital NHS Trust because I deal with many cases at other hospitals where similar things are happening on a day-to-day basis.’
You can watch the Sky News interview below.
The first report published in December 2020 outlined changes recommended by maternity services across England. The second report builds on these actions and shares new information that should drive the changes, ‘as a matter of urgency’. For, according to Ockenden, the ultimate intention of the report is to implement meaningful change in maternity services across England, in order to save lives and reduce harm, make the service more responsive to families and for the NHS to be more accountable for the service it delivers.
The primary findings of the second report are summarised below.
Failed maternity service
Encompassing the period 2000-2019, the 250-page report describes a trail of devastation involving maternal and neonatal deaths, stillbirths and birth injuries including brain damage, with particular focus at Shrewsbury and Telford NHS Hospital Trusts. Ockenden describes the Trust’s maternity service as a failure: ‘it failed to investigate, failed to learn, and failed to improve and therefore often failed to safeguard mothers and their babies’. Due to these failings, more than 200 babies and nine mothers died, who otherwise likely would have survived.
Inadequate investigation compounded ongoing poor care
The report found poor care to be an ongoing problem, partly because midwifery staff displayed a misplaced over-confidence in their clinical skills and a reluctance to seek support from other health care professionals when necessary.
Inadequate investigation procedures compounded the ongoing poor care. For example, 12 cases of maternal death were reviewed but only one of these was conducted externally. The internal investigation processes were sub-standard, ‘downgrading serious incidents’ to avoid external scrutiny’. Even the few external reviews provided ‘false reassurance’ about the service. This meant omissions in care were not recognised and opportunities to prevent further harm were missed.
Failure of leadership and oversight
However, the failures of Shrewsbury and Telford NHS Hospital Trust did not arise solely from the point of care. Issues around following national clinical guidelines, combined with a lack of collaborative working and an unhealthy culture within the Trust’s staff, resulted in a dysfunctional service. Staffing and training deficiencies within the medical and midwifery workforce also had a detrimental effect.
Then, when it came to the complaints process, clinicians were found to be lacking in compassion and were unprepared for briefings, while correspondence arising from the complaint’s procedure contained inaccurate information, justifications for care failures and blame of the families involved.
Ultimately, the report found that the Trust leadership failed to support staff and to implement service improvement and there was an overall lack of direction and accountability.
Recommendations from the review were issued to all Trusts offering maternity care in England. These included:
- Immediately increasing the budget for maternity services to £350 million annually, to ensure a safe workforce with minimum staffing levels, supported by robust, multidisciplinary training
- Accountability and timely implementation of improvements, with staff able to easily escalate concerns and the Trust board having oversight of care quality
- Clinical governance to ensure investigations and complaints are meaningful for staff and families
- An immediate suspension of the midwifery ‘Continuity of Carer’ model at all Trusts
In practice, the recommendations cannot be implemented in full
However important the Ockenden recommendations, a shortage of more than 2,000 midwives means in practice they cannot be fully implemented. The Royal College of Midwives chief executive said, ‘I am deeply worried when senior staff are saying they cannot meet the recommendations […] which are vital to ensuring women and babies get the safest possible maternity care’.
Despite additional funding for NHS maternity services, the lack of staff cannot be addressed immediately. Recruitment and retention must be managed in tandem, as Saffron Cordery, deputy chief executive of NHS Providers describes some Trusts having to close maternity services because of workforce gaps (ibid.).
Accountability for the past: police investigation
The impact of the negligent maternity care was profound. Families were harmed due to entirely avoidable failures of maternity care. Sajid Javid, the Health Secretary said that ‘those responsible for the ‘serious and repeated failures will be held to account’. Currently a criminal investigation is being carried out by West Mercia Police.
Looking at the situation now and into the future
The Ockenden report has made for distressing reading. It has exposed ‘uncomfortable truths’ for everyone involved in NHS England’s maternity services, requiring ‘deep soul-searching’ by maternity staff, managers and the Royal Colleges. Although the report is cited as a ‘blueprint’ for safe maternity care, and while improvements to the service have been made in light of its recommendations, it is clear that more needs to be done to keep women and babies safe now and into the future.
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