Listening to families and learning from clinical incidents at the heart of improving maternity care
Donna Ockenden has led a huge independent review of maternity services at The Shrewsbury and Telford Hospital NHS. The report is available here, and the findings are damning. The Trust repeatedly failed to learn from clinical incidents and failed to listen to families. In addition, the review found that the Trust’s governance procedures failed to hold the maternity services to account, and that external bodies failed to monitor the care provided effectively.
This final report of the Independent Maternity Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust is about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve and therefore failed to safeguard mothers and their babies at one of the most important times in their lives.Donna Ockenden, Chair of the Independent Maternity Review
The report has identified more than 60 Local Actions for Learning for the Trust, plus another 15 key Immediate and Essential Actions to improve all maternity services in England, in addition to the seven recommended in the first Ockenden report. We at GBSS fully support these actions, and we call on the Government to support Trusts in implementing them and making them a reality at all levels of maternity care.
It is heart-breaking to read of such poor care, where if only things had been done differently, babies and their mothers may not have died or suffered life-long disabilities. Group B Strep is a leading cause of serious infection in newborn babies. We could and should be preventing most of these awful infections – these brave families’ experiences show change is long overdue.Jane Plumb MBE FRCOG FRSA, Group B Strep Support Chief Executive
This report came about because of the persistence and dedication of parents – Rhiannon & Richard Stanton and Kayleigh & Colin Griffiths whose baby daughters Kate and Pippa died as a result of poor care and, in Pippa’s case, from a potentially preventable and treatable group B Strep infection. We and future families owe a huge debt of gratitude to them for speaking out repeatedly and not allowing the issues to be brushed under the carpet.
Now is the time for the Government to step up and support maternity services throughout England in implementing all of the Immediate and Essential Actions recommended without delay.
For more information:
Read the First Ockenden Report here.
Read the Final Ockenden report here.