Maternity services in England require minimum staffing levels after the Ockenden Review identified a lack of staff and training as the main reasons for failures at an NHS trust, which led to the avoidable deaths of more than 200 babies and life-changing injuries for many others.
Donna Ockenden’s independent review into maternity services at Shrewsbury and Telford Hospital NHS Trust (SaTH) provided a stark message to NHS England and government, requiring it invest more in the resourcing, training and oversight of maternity services nationally.
The review lasted five years, and examined 1,592 incidents affecting 1,486 families over two decades. It is understood to be the largest of its kind in NHS history.
Ockenden said: “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next. For example, ineffective monitoring of fetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.
Maternity staffing levels
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“The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved.”
The Ockenden inquiry found that at least 201 babies would have survived with better care, including 131 stillbirths and 70 neonatal deaths. Nine mothers also died as a result of poor care and 94 children needlessly suffered brain damage.
The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved” – Donna Ockenden, chair of the Ockenden Review
Javid will give a statement to Parliament later today but in a tweet he said he is “deeply sorry to all the families who have suffered so greatly and grateful to Donna Ockenden for carrying out this independent review”
The report acknowledged the £127million funding announced by NHS England for maternity services last week, but said it fell significantly short of the £200-£350million amount recommended by the Health and Social Care Select Committee last year.
Today’s report issued 60 specific recommendations for SaTH but also 15 “immediate and essential actions” for all maternity services in England including:
- NHS England must commit to a multi-year investment plan to ensure the provision of a well-staffed workforce. Appropriate, minimum maternity staffing levels must be agreed nationally, and locally, with these staffing levels adhered to.
- Essential action on training: sufficient protected time must be allocated for training across all maternity specialisms including routine refresher courses as well as multidisciplinary team training, particularly in emergency drills.
- Maintaining a clear escalation and mitigation policy when agreed staffing levels are not met: escalation should go to the senior management team, the Board, the patient safety champion and local maternity system. The Midwifery Continuity of Carer model must be suspended across all Trusts unless they can demonstrate staffing meets minimum.
Louise Barnett, chief executive at Shrewsbury and Telford Hospital NHS Trust said: “Today’s report is deeply distressing, and, on behalf of all at the trust I offer our wholehearted apologies for the pain and distress that has been caused.
“We recognise the strength and determination shown by the women and families involved and take full responsibility for our failings as a trust. This brings with it a duty to ensure that the care we provide today and in the future is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.”
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