Trusts should have 'oversight' of neighbouring providers, says damning safety review

The first tranche of findings from an independent inquiry into maternity services at Shrewsbury and Telford Hospital Trust has highlighted a catalogue of failings between 2000 and 2018.

The review, published today, is the first stage of an investigation into almost 2,000 cases, which will make it the largest clinical review into a single service in the history of the NHS. The second report is due to be published in 2021.

In a letter to health and social care secretary Matt Hancock, published alongside the report, the review’s chair, Donna Ockenden warned there is “a need for critical oversight of patient safety in maternity units”.

She adds: “This oversight must be strengthened by increasing partnerships across trusts within local networks of neighbouring trusts”

The review was commissioned by former health secretary Jeremy Hunt in 2017 and initially only covered 23 families. It was subsequently widened in 2018, while the trust also faces a police investigation.

The review said one of the most “disappointing” and “deeply worrying” findings was the “lack of kindness and compassion from some members of the maternity team”.

It found multiple examples were midwives “did not demonstrate the appropriate level of competence” and failures to escalate safety concerns to consultants during labour.

In relation to the trust’s own investigations of incidents, reviewers found reports and conclusions “failed to identify the underlying failings”. The report highlights repeated failures to learn from investigations and incidents by the trust.

The trust’s approach to bereavement was also criticised, with examples when “women were blamed for their loss.”

It also found evidence of “repeated attempts at vaginal delivery with forceps, sometimes using excessive force; all with traumatic consequences”.

In relation to this, it was found SaTH has had a lower caesarean rate than the national average, and had a culture focussed on keeping those rates low. While reviewers could not correlate this culture to poor overall obstetric care it did find examples were earlier caesarean would have avoided death and injury to babies.

According to the report the high turnover of executive director at the trust resulted in a loss of organisational memory.

Evidence also showed that concerns were raised outside the trust as early as 2013 in a risk summit led by NHS England and Telford and Wrekin Clinical Commissioning Group.

In her letter to Matt Hancock, Ms Ockenden said: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.”

The report makes 27 recommendations for immediate action both locally and nationally.

One of the cases which prompted the review was the death of baby Kate Stanton Davies in 2009.

In a statement her parents Rhiannon Davies and Richard Stanton told HSJ: “There have been countless reviews into maternity services at SaTH. There have been so many more for maternity services nationally.

“There is a deep-seated problem in maternity, a deeper seated problem in midwifery and a toxic issue at the heart of SaTH’s specific midwifery and obstetric services. Everyone deserves openness and the accessible information to help them make an informed choice. This is not forthcoming.

“In terms of midwifery, there is a culture of normal birth at any cost. This has pervaded for decades. Standards need raising, funding needs committing to this.”

SaTH’s chief executive, Louise Barnett, who joined the trust earlier this year, said: “We commit to implementing all of the actions in this report and I can assure the women and families who use our service that if they raise any concerns about their care they will be listened to and action will be taken.”

Nadine Dorries, minister for patient safety and maternity at the Department of Health and Social Care, said: “ I expect the trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families.”