The announcement made yesterday that £100m is to be spent improving maternity safety in England in response to the report of Donna Ockenden, chair of the Independent Review of Maternity Services at Shrewsbury and Telford Hospitals NHS Trust, published in December 2020 has been universally welcomed.
This investment is inclusive of a £500,000 fund for NHS maternity leadership announced by Patient Safety Minister, Nadine Dorries and it is understood that 1,000 midwives and around 80 obstetrics consultants, many from overseas, will also be hired.
The Ockenden report was requested in 2017 by former health secretary, Jeremy Hunt, following a high number of baby deaths at the Trust. Donna Ockenden identified seven “immediate and essential actions”, and this funding announcement appears to address those concerns.
Those “essential actions” included ensuring women are provided with adequate information to enable them to make informed decisions about their pregnancy and birth, a dedicated lead midwife at each unit, risk assessments to be completed at each contact during a woman's pregnancy, ensuring midwives and consultants train together and better investigations when things go wrong.
Initially there were 23 cases being investigated by Ockenden, but the inquiry looked at 250 cases and has received a total of 1,862 cases for review. The preliminary report was compiled after independent clinicians considered those initial 250 cases. One of these concerned a client of Alex Haider, associate solicitor in Shoosmiths clinical negligence team. The clinicians’ report made reference to the case as follows:
‘A pregnant woman who was known to have large uterine fibroids had midwifery led care and was not referred to an obstetrician as her condition should have required. There were errors in the interpretation of the baby’s growth and an obstetric opinion or ultrasound scan was not obtained. The baby was delivered around ten weeks early, was growth restricted and died the same day from a severe hypoxic birth injury’.
“Notwithstanding the report’s findings, in this case the Trust’s representatives, NHS Resolution (NHSR), maintained their denial of liability for the premature birth and death of the baby. Settlement was agreed prior to the issue of court proceedings on a full liability basis, but without a formal admission of liability. My client and her husband’s main motivation in pursuing this claim was to highlight the failings of the Trust to help ensure that lessons were learned. I am sure this announcement of extra funding will be welcomed by them and many other families as evidence that those lessons have indeed been taken on board and acted upon.”
Prior to the publication of the Ockenden report The entire Shrewsbury and Telford Hospital NHS Trust had been put into special measures by NHS Improvement (NHSI). This was an unusual step to take without a recommendation from the Care Quality Commission (CQC), to which the Trust had been reporting in connection with its performance and was indicative of the seriousness of the situation.
Kashmir Uppal, a partner specialising in clinical negligence at Shoosmiths said:
‘The concerns about the Trust's quality and performance in maternity services in particular were entirely justified. I am pleased that the prompt announcement of this additional and substantial funding is on a scale that recognises the serious nature of problems, not just at this particular Trust, but across maternity services throughout England. Hopefully this investment in training and recruitment will have an impact on direct front-line care as quickly as possible and reduce the incidence of events that result in the tragically avoidable loss of life’.