Serious complications and deaths resulting from maternity care have an everlasting impact on families and loved ones. The families who have contributed to the Ockenden Review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past.
The learning of lessons and embedding of meaningful change at The Shrewsbury and Telford Hospital NHS Trust and in maternity care overall is essential both for families involved in this review and those who will access maternity services in the future. After reviewing 250 cases and listening to many more families, this first report identifies themes and recommendations for immediate action and change, both at The Shrewsbury and Telford Hospital NHS Trust and across every maternity service in England.
Immediate and essential actions
1) Enhanced safety
Essential action - Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks. Neighbouring Trusts must work collaboratively to ensure that local investigations into Serious Incidents (SIs) have regional and Local Maternity System (LMS) oversight.
2) Listening to women and families
Essential action - Maternity services must ensure that women and their families are listened to with their voices heard.
3) Staff training and working together
Essential action - Staff who work together must train together.
4) Managing complex pregnancy
Essential action - There must be robust pathways in place for managing women with complex pregnancies Through the development of links with the tertiary level Maternal Medicine Centre there must be agreement reached on the criteria for those cases to be discussed and /or referred to a maternal medicine specialist centre.
5) Risk assessment throughout pregnancy
Essential action - Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway,
6) Monitoring fetal wellbeing
Essential action - All maternity services must appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion best practice in fetal monitoring.
7) Informed consent
Essential action - All Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.