- Senior midwife Donna Ockenden appointed to lead review into deaths of 15 babies and three mothers
- Parents criticise NHS Improvement for setting “narrow” terms of reference and excluding families
- Jeremy Hunt set up review after concerns over deaths and lack of investigations
A senior midwife has been appointed to lead an inquiry into the deaths of 15 babies and three mothers at an NHS trust.
Donna Ockenden – an adviser to the Nursing and Midwifery Council, Royal College of Midwives and a clinical director of the London Maternity Strategic Network for NHS England – will lead a review into maternity care at Shrewsbury and Telford Hospital Trust.
However, the inquiry is already facing criticism from families whose children died after poor care at the trust. They said the review’s terms of reference are too narrow and exclude other families who have since come forward so will not identify potential systemic causes of poor care.
An NHS Improvement spokeswoman said it hoped the review would lead to wider learning and the regulator could carry out a second review if it was necessary.
Jeremy Hunt ordered the review in April after concerns were raised that more than a dozen other babies had died because of errors that were not properly investigated.
The terms of reference for the review said the inquiry team would include two midwives, two obstetricians and two neonatologists.
Questions they will seek to answer include:
- Did the trust have in place at the time of each incident mechanisms for the governance and oversight of maternity incidents? Does the trust have this now?
- Were incidents and investigations reported and conducted in line with the time-relevant national and trust policies?
- Is there any evidence of learning from any of the identified incidents and the subsequent investigations?
- Were families involved in the appropriate and sympathetic way?
The avoidable death of baby Kate Stanton-Davies in 2009 was described in an independent review by expert Debbie Graham as having “echoes of Morecambe Bay”. Kate’s parents believe the review announced by NHSI does not go far enough.
Her mother Rhiannon said: “The [trust’s] board were extensively criticised by Debbie Graham in both of her reports for NHS England and the trust. If management are not held to account, what is the point?
“There are other families who have not had any response. We have had a very defensive reaction from the trust in recent weeks; the relationship between us and the trust has broken down irrevocably.”
She said the death of baby Pippa Griffiths a year ago had resulted in the trust treating her family in the same way. She added: “It’s not that Pippa died, but how they responded to her death. How can we trust them?”
Pippa’s mother Kayleigh Griffiths said she was concerned about the terms of reference. “I don’t see how they can exclude other families that have come forward. Their babies are just as important as the ones being investigated.
“It needs to be a full public inquiry. They are focusing on what is in the notes but they need to look at all the documents and evidence including those held by families. They are not going to find things just looking at the notes. This inquiry is not going to give us the full picture if they exclude half the families,” she said.
An NHSI spokeswoman said the inquiry would look at the quality of the trust investigations rather than the circumstances of cases.
She said: “While we can’t currently extend the scope of the review beyond the set of cases currently included, we fully expect every learning identified from the review to help investigations into cases with similar circumstances and shape improvements across the trust.
“We also reserve the right to proceed to a second stage review should the circumstances or our findings require it.”
NHSI said Ms Ockendon would meet families “to ensure they have as much input and involvement into the process as they would like”.
Following the announcement of the review, trust chief executive Simon Wright said the trust was committed to being open about what had happened. He said: “We have investigated all of these cases. We have also commissioned a number of independent external reviews to help us make sure our services are even safer and better and have implemented any learning from these.”
He said the trust could not comment further while the review was underway.
Information supplied to HSJ