The Ockenden Report

30/03/22 – FINALLY the day when the Ockenden report was published, after 5 years of waiting this day will be monumental for a lot of families, and in fact a mile stone for maternity care moving forward. And made for truly disturbing and upsetting reading…

Working in the role that I do within the NHS, this report has brought a lot of uneasy feelings forward, mainly around what I do and what impact I’m actually making on the NHS (the reason I joined in the first place…) and actually? Not a great deal…It has been a heavy day work wise, whilst I don’t work directly with maternity services, it is a wide area of the scope in which I am employed. Which means I probably know more than the general public about the findings of this report and the truly catastrophic failings.

Going back to 2017 I was employed by the Care Quality Commission, whilst I can’t go into too much detail I recall being involved with the inspection report of the trust investigated in the Ockenden report and reading Rhiannon and David’s story regarding the death of their daughter Kate Stanton-Davies at Shrewsbury and Telford. I read that inspection report, I was in meetings where it was discussed at Exec level. This was 5 years ago and today we are STILL on the same topic…5. YEARS. It is over 200 pages long and is basically 200 pages of harm. 131 stillbirths, 201 deaths where concerns were found, 70 neonatal deaths and 9 maternal deaths…My heart is so heavy today and have been hugely triggered by this report – both professionally and personally.

Just to give a bit of background, The review was commissioned in 2017 by the then Secretary of State for Health and Social Care, Jeremy Hunt following the death of Kate Stanton-Davies.  Since the launch of the review many more families have come forward with concerns about their care at the trust. An interim report was released last year but the final report was published today. The report gave a voice to ignored families, when they tried to raise concerns up to 20 years prior….and were ignored.

Key findings:

  • More than 200 babies may have died and many others left with life-changing injuries due to repeated failures at Shrewsbury and Telford NHS Trust between 2000 and 2019
  • Mistakes were not investigated and there was a failure of external scrutiny
  • There was a reluctance to perform caesarean sections which resulted in many babies dying during birth or shortly afterwards
  • In many cases, mothers and babies were left with life-long conditions as a result of their care
  • Parents were not listened to when they raised concerns about the care they received
  • There was a tendency to blame mothers for their poor outcomes, in some cases for their own deaths
  • Where cases were examined, responses were described as lacking “transparency and honesty”
  • The trust failed to learn from its mistakes, leading to repeated and almost identical failures
  • A culture of bullying, anxiety and fear of speaking out among staff at the trust “that persisted to the current time”

In addition, 15 “immediate and essential actions” for all maternity services in England were put forward, covering 10 key areas, including that NHS England must commit to a long-term investment plan to ensure the “provision of a well-staffed workforce”. I am employed by NHS England and whilst I’m a very small fish in a very large pond, there is an elephant in the room about accountability.

There are huge positives to this report, that identify real areas for change and will finally give a lot of leverage to trusts and midwifery teams that changes HAVE to be made, mandated changes which I’m sure a lot of health professionals have been trying to make for a long time and will welcome.

But mostly I am tired, I am just so very tired and so incredibly sad for all of these families. In fact today, I feel sadder today than I have in a very long time. For Ollie, our beautiful son, for the other parents within this community and for every parent who has been failed by a system that we trusted. For every husband who lost their wife, for every Aunty, Uncle, sister, brother, friend, cousin, colleague I am sorry. I am just so incredibly sorry.

I want to ask Calderdale Hospital – Aside from the mandated requirements for change following the report, what have the trust done or plan to do as a result of this report being published? When I was in labour, midwifery staffing was 33% down at the trust. I was left for over 1 hour with bleeding in maternity assessment before being seen. Ollie’s movements were sluggish for 3 weeks prior to his death. Could more have been done? We are still awaiting some results but after reading this, I don’t know…

Every woman has the right to a safe birth. Regardless of history, circumstances, health, religion, culture, personal life. Will this finally be the wake up call the government and the NHS needs? I hope so, only time will tell…

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