The Ockenden Review into the death or serious injury of babies and mothers at the Shrewsbury & Telford NHS Trust maternity unit revealed a shockingly high number of affected families (1486).
Most people following the story probably assumed that this was a real outlier – how can so many individual lives have been ruined over such a long time without any action being taken? But as Donna Ockenden's current review into Nottingham University NHS Trust's maternity units has revealed, Shrewsbury was no outlier: she and her team are looking at the files of approximately 1800 families who are thought to have been affected by poor treatment at Nottingham's Queen's Medical Centre and Nottingham City Hospital. The announcement that the Trust is now also the subject of a police investigation will have compounded the agony for the families concerned.
Tenacious families uncover extent of maternity failings.
If it wasn't for the determination of the families involved
to find out why their babies died or were injured - and their
refusal to take no for an answer - their harrowing tales of poor
treatment may never have come to light. They were not alone in
their fight for the truth – Trust employees had also
repeatedly raised concerns, particularly around inadequate staffing
levels, which were ignored. A CQC assessment in 2020 rated the
maternity units inadequate with insufficient numbers of staff to
provide a safe level of care, poor leadership, and a culture that
failed to learn from past mistakes. If this sounds familiar, it is.
The same types of criticism were levelled at Morecombe Bay,
Shrewsbury and East Kent. Indeed, as Dr Bill Kirkup noted in his
review of the failures at East Kent, there was no point in
recommending how the Trust could improve as such recommendations
were routinely ignored.
The Chief Constable of Nottingham announced that her force would be
looking at West Mercia Police's 2020 investigation of
Shrewsbury & Telford to help them frame their investigation and
that they would be working closely with Donna Ockenden and her
review team. Whether or not the police will uncover sufficient
evidence to bring criminal charges against either individuals or
the trust remains to be seen but it does give an indication of how
seriously the matter is being taken.
Management is ultimately responsible.
The importance of good management in hospitals was brought sharply into focus in the Lucy Letby case where the senior leadership's failure to listen and act on concerns about her was a cited as a major factor in her being able to continue working on neonatal wards with devastating results. Time and time again, when reviewing cases of poor care, it is almost always poor leadership that sits at the centre of the problem. Most hospitals, and particularly maternity units have a problem with staffing, but the vast majority do a good job under difficult circumstances. The common failings identified by the various reviews into maternity scandals include staff indifference, poor relations between midwives and obstetricians, lack of oversight, inadequate training levels, ideological adherence to 'vaginal delivery good, caesarean delivery bad', a refusal to admit mistakes, lack of transparency, and a reluctance to listen to patients' concerns. And the common factor in all these scandals? Deficient management.
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