The final Ockenden report has published a list of 15 immediate and essential actions (IEA’s) that are needed to improve maternity services across England as well as over 60 local actions for learning.
The findings have been authored by Donna Ockenden after she was appointed by former Health Secretary, Jeremy Hunt to conduct an independent review into maternity services at Shrewsbury and Telford Hospital NHS Trust.
The report comes after relentless efforts from two families who lost their children shortly after being born at the trust.
Initially the report voices the repeated and extensive list of failings made by the maternity services at Shrewsbury and Telford Hospital NHS Trust such as failure in governance and leadership an overall poor care.
As well as reviewing the maternity care of 1,486 families between 2000 and 2019, the Ockenden report also heard from 60 present and former staff members on their opinions of the maternity services they worked within.
The IESs issued to maternity services includes:
Investment to fund maternity and neonatal services appropriately to create a safer maternity workforce.
All trusts must maintain a clear escalation and mitigation policy where maternity staffing falls below minimum staffing levels.
Clinical governance: Trust boards must show leadership and have oversight of the quality and performance of their maternity services.
Regular mandatory staff training for staff who work together.
Trusts must ensure any women who suffer from pregnancy loss are offered appropriate bereavement care services.
In response to the report, Health and Social Care Secretary, Sajid Javid spoke in the House of Parliment: “Due to this tragically high number of cases and the importance of this work to patient safety early conclusions were published in an initial report in December 2020. We accepted all of the recommendations from this first report and the NHS is now taking them forward.
“Today, the second and final Report has been published.
“This is one of the largest inquiries relating to a single service in the history of the NHS looking at experiences of almost 1,500 families, from 2000 to 2019. I’d like to update the House on the findings of this report, and then turn to the actions that we are taking as a result.
“This report paints a tragic and harrowing picture of repeated failures in care over two decades which led to unimaginable trauma for so many people.”
Sajid Javid, Health and Social Care Secretary
Amongst the vast number of findings, 44 cases of Hypoxic ischaemic encephalopathy (HIE) were revealed. Two thirds of the cases reviews featured ‘significant and major concerns’ in the care given to the mother.
The report also uncovers that from the near 500 stillbirths recorded between 2000 and 2019, one in three were found to have major concerns in maternity care which could have resulted in a different outcome had it have been managed appropriately.
You can read the full final Ockenden report here.