30th March 2022
- Baby Lifeline whole-heartedly welcomes the Ockenden Review released today, and supports its immediate and essential actions for urgent reform in maternity services locally and nationally, including calls for:
- An additional £250-300 million for maternity services nationally
- A national set of training targets
- Safe staffing levels
- Proper investigations of complaints and serious incidents.
- The report looks at almost 1,600 clinical incidents of harm at Shrewsbury and Telford NHS Trust (SaTH) between 2000-2019 including stillbirths, neonatal deaths, maternal deaths, and brain injuries. Sadly, the concerns over the care provided were graded as “significant” or “major” in many of these cases.
- Baby Lifeline is working with SaTH on multi-professional training in key areas highlighted by the interim and new report.
The Ockenden Report, published today, reports the tragic findings from 1,592 real clinical incidents of harm at The Shrewsbury and Telford Hospital NHS Trust (SaTH) between 2000-2019. The clinical incidents include stillbirths, neonatal deaths, maternal deaths, and cases of hypoxic ischaemic encephalopathy (HIE; a brain injury caused by a lack of oxygen or blood flow during labour). The report demonstrates a need for support and investment in SaTH and also in wider maternity services.
The families that have had to campaign for change at SaTH and other maternity services across the UK have been instrumental in the safety and quality improvement work already happening, but the report published today is a further reminder that essential work needs to be done, and immediately.
Led by expert midwife Donna Ockenden and her multi-professional team of more than 90 on-the-ground midwives and range of doctors involved in maternity and neonatal care, the report outlines “a road to safety” for maternity services both at SaTH and further afield. As a charity that trains multi-professional teams to deliver the best outcomes for mothers, birthing people and babies, we know that including the whole team in quality improvement is paramount to its success.
We are encouraged by the report’s use of “actions” and not “recommendations”; with this sense of urgency around much-needed change, this is an opportunity for every mother, birthing person, and their baby to have the safest and best care throughout their maternity journey.
The report outlines more than 60 new local actions for learning for SaTH covering 9 key areas: improving management of patient safety, patient and family involvement in care and investigations, improving complaints management, care of vulnerable and high-risk women, diabetes care, multi-disciplinary working, midwifery-led units and out-of-hospital births, staffing, and communication with GPs.
The report also highlights 15 immediate and essential actions for improving maternity services in England, which need to start happening now. The key areas cover all aspects of care, including care of staff:
- Training targets: The report supports Baby Lifeline’s call for a national set of training targets and sufficient time allocated for staff to attend – something which will ensure that key training priorities are universal, and professionals are given the same amount of support to give the safest care and trained to the same standard.
- The report found repeated failures in care in areas identified as paramount to risk assessing babies at risk of stillbirth and neonatal death (for example, ineffective monitoring of fetal growth).
- Baby Lifeline surveyed health professionals responsible for maternity training in 2021 in their ‘Mind the Gap’ research and found that fewer than half of respondent UK maternity services provided all training recommendations outlined for the Saving Babies’ Lives Care Bundle to improve risk assessment, prevention and surveillance of pregnancies at risk of fetal growth restriction.
- An increase in funding: The report supports the Health and Social Care Committee’s recommendation “that the budget for maternity services be increased by £200–350m per annum with immediate effect”, along with other recommendations from the HSCC report.
- Proper investigations into complaints and harm: The report identified hundreds of cases where the Trust failed to undertake serious incident investigations, where problems identified and changes made would have saved lives. The report calls for proper investigations of incidents, which will require quality training for professionals conducting them. It also calls for rapid action on recommendations within 6 months of the incident, to alleviate some of the burden for families.
- Baby Lifeline surveyed health professionals responsible for maternity training in 2021 and less than one third of organisations (32%) provided training in conducting serious incidents investigations to relevant staff across the UK.
- Workforce funding and safe staffing need to be a priority.
- Trust boards need to be accountable for maternity services but need funding to support that accountability.
Baby Lifeline’s work is centred around making birth safer and better for every mother and baby and provides expert-led training focused on key areas that relate to avoidable harm and deaths in maternity care. We are working with SaTH to provide their workforce with multi-professional training in key areas identified by the report.
Judy Ledger, CEO and Founder of Baby Lifeline, says:
“This important report tells the tragic stories of what nearly 1,600 families have had to endure due to poor standards of maternity care, and we owe it to them to act now to ensure that every mother, birthing person, and their babies have the safest and best care. We welcome the report’s urgent pursuit of change in maternity services nationally with its ‘immediate and essential actions’ in place of ‘recommendations’.
There have been many reports before, asking for funding, asking for systems to change, and asking for standardisation and guidance to achieve best practice – it is not acceptable, therefore, that themes in poor standards of care are repeating. A culture of blame and defensiveness within the NHS is inhibiting an opportunity to progress and make care better: families need to be heard as soon as something happens, and those caring for them need to be supported with safer levels of staffing and the right training. We welcome the announcement about increased funding for maternity services, especially for workforce increases and better training in areas of avoidable harm.
We hope that today’s thorough and important report is the start of a journey that will ensure that every mother, birthing person, and baby has the safest and best care.”
ENDS————–
For more information about Baby Lifeline or for comment, please call – Sara Ledger (07572 037537) or the Baby Lifeline office (01676 534671).
Background information on Baby Lifeline
Baby Lifeline was founded 40 years ago by nurse Judy Ledger, following the personal tragedy of losing three premature babies. The charity has purchased millions of pounds’ worth of equipment for maternity and neonatal units, produced nationally recognised reports and research projects, and provided continuing professional development training for over 25,000 maternity healthcare professionals, with 10,000 of these receiving training in the past three of years. Predominantly training UK professionals, the charity has ventured to other parts of the world including Kuwait, when shortly after the last Gulf war Baby Lifeline worked with army humanitarian units and the British Embassy to train Iraqi and Kuwaiti health professionals.
Baby Lifeline is a truly unique organisation that works to support our wonderful NHS professionals in preventing avoidable tragedies in pregnancy and childbirth. The way that it operates is highly collaborative and unique. A panel of world-renowned multi-professional experts informing its decisions, and its training delivered by frontline NHS professionals. Baby Lifeline works closely with a wide range of national and international organisations, recognising that it can only truly achieve the goals if everyone is pulling in the same direction.
There have been some tremendous advancements in maternity care in recent times, but it is widely recognised that more needs to be done, particularly if the Government wants to meet its ambition to halve stillbirth, neonatal and maternal deaths by 2025.