Nobody expected the Ockenden report published last week to be an easy read. However the breadth and pervasiveness of the issues at Shrewsbury and Telford Hospital NHS Trust over such a prolonged period of time is staggering to comprehend. That this led to the avoidable deaths of women and hundreds of babies is absolutely heart-breaking and that numerous opportunities to learn lessons were missed is truly devastating. The thoughts of the whole Birthrights team are with all of those families whose stories fill the pages of this landmark report.
Lack of staff and the contribution this made to poor care is highlighted throughout. This is concerning given the levels of staff attrition across the NHS and especially in maternity care at present. Safe staffing is not sufficient to guarantee safe and personalised care but it is a necessary foundation for it. Birthrights wrote to Sajid Javid, the Secretary of State for Health and Social Care, last November urging the Government to accept the Health and Social Care committee’s recommendation to invest an extra £200-£350m a year and to urgently publish a retention plan for maternity staff. Donna Ockenden was clear that she also backed the Health and Social Care Committee’s recommendation and was equally clear that the £127m two year funding announced last week fell significantly short of what is needed. Sajid Javid said in Parliament that he would keep this under the review. It’s hard to comprehend what further evidence would be needed in order to make the case for investment immediately. Birthrights will continue to campaign for proper investment in maternity services to support recruitment, retention and training.
Human rights law entitles us all to be treated with dignity. And yet the Ockenden report painstakingly paints a picture of a culture where listening to others and basic levels of respect had gone out of the window. Time and time again women and birthing people were not listened to, belittled and dismissed. One woman who was concerned her waters might have broken was told she had probably wet herself, women with reduced fetal movements were sent away, and concerns about newborn babies, such as Pippa Griffiths, were not investigated with tragic consequences.
Birthrights’ maternal request caesarean campaign in 2018 highlighted the lack of willingness to accept that women and birthing people were capable of making their own informed choices about the best mode of birth for them. Only 26% of Trusts had guidelines that followed the NICE recommendation to offer women making an informed choice a caesarean birth. Shrewsbury and Telford’s false pride in its low caesarean rate has been well publicised and hopefully the Ockenden report will send shivers down the spines of many Trusts whose policies are still out of step with NICE guidance despite NHSE having been clear that caesarean targets are no longer acceptable. But it’s also important to highlight that the issues at Shrewsbury and Telford went so much wider and infected every corner of the service. The report is nothing if not thorough in examining each stage of the maternity journey and the harrowing experiences recounted to the team. Oxytocin was misused. Negligent instrumental births took place with alarming regularity. Women with more complicated pregnancies such as expecting twins/triplets or who were diabetic received poor care, as did babies with restricted growth or who required more specialist intensive care that Shrewsbury and Telford wasn’t mandated to give.
Women were not given the evidence based information they needed to make informed choices about the safest place for them to give birth or safest mode of birth even following the landmark Montgomery v Lanarkshire decision which changed the law on consent in 2015.
When staff tried to raise concerns they were also silenced. Poor multi-disciplinary relationships among staff meant that concerns weren’t escalated or when escalated were not responded to.
And critically when something went wrong, the system did not learn lessons. In fact incidents were downgraded so they would not be subject to external scrutiny. 40% of stillbirths and 43% of neonatal deaths between 2011-19 weren’t investigated at all.
In 2015, the same year that the landmark Montgomery v Lanarkshire judgement which changed the law on consent was handed down and the Morecambe Bay report was published, Birthrights wrote to the national maternity review to urge the review team to strive for safe and personalised maternity care based on recognising fundamental human rights to be treated with dignity and respect, to make informed choices and to have those decisions supported:
Sadly this letter is as relevant today as it was seven years ago. If only the lessons had been learnt in 2015, if not long before, it is sobering to contemplate the number of lives that would have been saved.
It is easy to read the Ockenden report and despair, particularly when other failures in other units are never far from the front pages.
However in these darkest of times we all need to cling on to hope.
First of all, there is hope in the near universal shock and disbelief that failings of this scale were allowed to happen, after so many opportunities to make wholesale change both at the Trust and within the wider system have been missed. Even where there are differences of emphasis and approach, nobody can be left unmoved by what happened at Shrewsbury and Telford, and we need to build on what unites us, not what divides us, to ensure that there is a different response this time. The Immediate and Essential Actions will go a long way towards filling gaps in safe practice. They will not necessarily deliver the deep cultural change in maternity services that is needed to really put women/birthing people at the centre of their care but with the right focus they could be the start of that journey. We were surprised that the report did not place more emphasis on the powerful and evidence based contribution that continuity of carer can make to safety, but will work with our partners on the Stakeholder Council to ensure all Trusts are in a position to make progress on implementing this model of care as soon as staffing levels allow.
Secondly there is hope in the good practice that currently exists in this country. The Royal Colleges and NHS England have reminded us in a letter to The Times newspaper this week that most births are safe. Indeed the Ockenden report generously shared examples of good practice demonstrating what it is possible to achieve even in the most toxic of cultures. Reports into failings necessarily pull out the lessons we need to learn from the worst examples of care. But it is equally important that we seek out and learn from best practice too in order to move forward.
Thirdly, there is hope in the fact that we can all speak up and speak out and play our part in being the change we want to see.
If you are an individual using maternity services and you don’t feel listened to or respected, or something doesn’t feel quite right, we urge you to #SpeakUpandSpeakOut. If you want to understand more about your rights and how to speak up if something is not right, take a look at our factsheets or contact us on firstname.lastname@example.org. We are here to support you, and those around you. While the burden should not be on women/birthing people and their families and supporters to change maternity services, as more and more individuals challenge unacceptable practice, maternity providers and their political masters will have to respond.
If you are reading this as a healthcare professional, we know that you came into the profession to care and not to cause harm. We have already lost too many healthcare professionals who feel they are losing the battle to be able to deliver the care they want to give. Today we urge you to rediscover and use your voice, even if you have not been heard before. You may not be able to change the number of staff on your shift, but a kind word to a labouring woman or colleague can make the world of difference and costs nothing. If you have serious concerns about what you are witnessing around you, raise them with a manager, or the Maternity Safety champion. Staff are also able to report concerns directly to the new Special Health Authority which will be able to investigate. Make sure issues raised are minuted, actions agreed and risk registers updated. Seek out like minded colleagues and look to make change together. If you are concerned that families are not being treated with dignity, or that choices are being denied, you can contact us in confidence on email@example.com. You could also ask your Trust to consider commissioning our training. We are here for you too.
We reaffirm our commitment to working with all of you to achieve the safe, personalised and rights based maternity services we all want to see.
Watch our video Speak Up, Speak Out
Birthrights is the UK charity that champions respectful maternity care by protecting human rights. We provide advice and legal information to women and birthing people, train healthcare professionals to deliver rights-respecting care and campaign to change maternity policy and systems.
For media enquiries or to arrange an interview with a spokesperson please contact:
Francesca Treadaway, Engagement Director, firstname.lastname@example.org.
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