Ockenden report into maternity care failures: what difference will it make?

Coodes Solicitors’ Partner and clinical negligence specialist Julie Hatton comments on the forthcoming Ockenden report, an investigation into maternity care failures in Shrewsbury and Telford Hospital NHS Trust.

In the coming weeks, the Ockenden report will be published. The biggest investigation ever carried out into NHS maternity care has examined the experiences of 1,862 families over 20 years. Tragically, this included the deaths of more than 12 women and 40 babies.

We are waiting to see the full report, which has been chaired by former midwife Donna Ockenden. However, we already know that the inquiry has revealed what has been described as a “toxic culture”, in which lessons were not learned, leading to mistakes being repeated.

An initial report, which was published in December 2020, outlined key areas where the Trust had failed, including:

• Excessive use of forceps.
• Repeated misuse of a labour- inducing drug.
• Failure to escalate concerns to senior clinicians.
• A lack of compassion and kindness in the delivery of care.
• Failure to properly monitor babies’ heart rates leading to babies being born with severe brain damage.

The report also raises questions about leadership, with 10 CEOs heading-up the Trust between 2000 and 2020 (and eight in the last 10 years). The initial findings suggest this led to a loss of organisational memory and a tendency to view problems as historic.

Raising awareness among other families

The investigation has already attracted significant media coverage, including being the subject of a BBC Panorama documentary.

The full report is likely to attract significant media attention, but what difference will this make to families in the future?

Firstly, uncovering the poor maternity care at this Trust, and the long-term impact that had on so many parents and babies, could encourage more people to speak out about their own experiences.

We support many people who have suffered birth injuries. I am often struck by the fact that so many of them are initially unaware they have cause to complain. Sometimes mothers who suffered inadequate care when having their first baby did not know what to expect so were simply unaware that their experience fell below the expected standards. Those parents with little family support are particularly vulnerable to this.

Many people are also unaware that an injury that affected them or their baby was preventable and could have been avoided if the right care had been given. This means they don’t then speak out and try to find out what went wrong.

People are all too often unaware that they can ask questions, challenge medical staff or complain when things do not feel right. In the very sad event of a mother or baby dying during or shortly after a birth, family members do not always initially feel that they want answers. However, over time this can become more important and provide some closure.

I hope that one positive that could come out of this shocking report is for more people to realise that they can question their care. After all, the Ockenden investigation happened because two brave couples spoke out about the devastating loss of their babies and campaigned for this independent review.

Preventing future loss

The interim report points at multiple failings in a dysfunctional culture. When it is published, the final report will doubtless highlight many shocking findings. Sadly, many of the experiences shared by couples in the interim report are familiar to me. Although the scale of the failures at the Shrewsbury and Telford Hospital NHS Trust are staggering, we have dealt with individual cases of families suffering similar experiences in other hospitals.

While the purpose of making a clinical negligence claim is to secure compensation to support those affected to get their lives back on track, this is not the only motivation. Many of our clients come to us because they want their voices to be heard and want healthcare providers to learn from their experiences. I often hear people say: “I don’t want anyone else to go through what I’ve been through.”

While the final report will no doubt be a difficult document to read, I hope that, by highlighting failures, it will prevent future losses.

Bringing about positive change

The initial report sets out 27 actions for the Shrewsbury and Telford Hospital NHS Trust and seven for the whole maternity care system.

One key finding outlined in the initial report was around the Trust’s low caesarean section rate. It stated that women “appeared to have little or no freedom to express a preference for caesarean section or exercise any choice of their mode of delivery.” Caesarean section rates were considerably lower than the national average and the report suggests this was worn as a “badge of honour” by the Trust. Sadly, this led to some of the deaths and injuries that have been investigated.

As a result of this issue being raised in the initial report, the NHS has now dropped targets for ‘natural births’.

We are yet to see what recommendations are published in the final report. However, I hope the report will bring about positive steps to improve maternity care, not just at the Shrewsbury and Telford Hospital NHS Trust but in all hospitals.

For further information or advice on these issues please contact Julie Hatton in Coodes Solicitors’ Personal Injury team on 01326 214036 or Julie.hatton@coodes.co.uk.