The Ockenden review into maternity services at Shrewsbury and Telford hospitals uncovered a pattern of repeated serious harm to mothers and babies.
The review into the first 250 cases, out of 1,862 serious cases, also identified a series of “missed opportunities to learn in order to prevent serious harm to mothers and babies”.
Particular areas of concern highlighted in the report include:
Lack of compassion and kindness
The review found the “lack of kindness and compassion” displayed by the members of the maternity team was “one of the most disappointing and deeply worrying themes”. Some bereaved parents were offered no words of condolence, while one mother said the trust’s bereavement service made “it so many times worse”. A mother who was in agony in birth said she felt “pathetic” when she was told her pain was “nothing” and she was being “lazy”.
Reluctance to conduct caesarean sections
Caesarean section rates at the trust have been 8% and 12%, consistently below the English average of 24% to 29%. The review team found a culture of trying to keep C-section rates low, because of a belief that this was a sign of good maternity care. But the review found earlier recourse to caesarean delivery would have avoided death and injury in many cases.
Maternal deaths
The review found that 13 women died in childbirth between 2000 and 2019, in some cases due to recurrent failings. It found a lack of planning in the care for women with underlying health problems, resulting in fatal delays in their treatment. The reviews into these deaths also lacked “rigour and quality”, hampering the trust’s ability to learn from mistakes in care.
Blaming mothers
Hospital reviews of serious cases were sometimes “cursory”, failed to identify underlying failures in care, and sometimes blamed mothers. Correspondence about cases were found to have “focused on blaming mothers rather than considering objectively the systems, structures and processes underpinning maternity services”. The review said: “There are several examples where mothers say that they were made to feel responsible by trust staff for the loss of their babies.”
Poor care in complex cases
The review identified poor oversight by consultants in high-risk pregnancies. In 2011 there were delays in the treatment of a mother’s high blood pressure. This continued after the birth and she subsequently died in another hospital. The review also found repeated failures to escalate cases for further review. In 2015 a baby was stillborn after the midwife failed to monitor the fetal heart rate and the baby’s mother with high blood pressure was induced. The family received no apology.
Injudicious use of oxytocin
Oxytocin, a drug used to increase contractions, was often used too frequently in labour despite the known risk it posed to fetal heart rate. In 2006 a breech birth baby died after the inappropriate use of oxytocin, despite guidance against the use of it in breech births. In 2014 another baby died after the excessive use of the drug despite evidence of the baby’s deteriorating condition.
Traumatic births
The review found evidence in several cases of “repeated attempts at vaginal delivery with forceps, sometimes using excessive force, all with traumatic consequences”. In 2007 a baby died after suffering multiple skull fractures from forceps.
