Ignoring women’s experience led to the NHS’s biggest maternity scandal (BMJ, 7 April 2022)

Summary

The Ockenden review of maternity services at Shrewsbury and Telford NHS Trust uncovered the biggest maternity scandal in the NHS’s history. The report concludes that 201 babies and nine mothers might have survived if they had received better care and raises serious questions about how avoidable deaths and injury to so many mothers and babies could have happened 

Staffing pressures, training gaps, and overstretched rotas all contributed. But so did a failure to follow clinical guidelines or to investigate and learn from mistakes. Staff did not listen to patient experience, women were blamed or held responsible for poor outcomes—even their own deaths—and there was a lack of compassion in how patients were treated and responded to. Inadequate leadership and a bullying culture left staff feeling unable to raise concerns or escalate problems

Is there a failure to listen to women across the NHS? Why are women’s voices ignored and their health concerns brushed aside?