🚨BREAKING: Repeated care and governance failures were routinely ignored by a hospital trust where poor maternity care resulted in 295 avoidable baby deaths or brain damage cases, final @DOckendenLtd report into maternity at Shrewsbury and Telford Hospital Trust finds
Nine mothers also died as a result of avoidable poor care and there were concerns for an additional three mothers’ but #ockendenreview found outcome would have been the same
Review of 1,600 clinical incidents identifies repeated care and governance failures over decades. @DOckendenLtd says both @sathNHS and multiple external bodies failed to listen to families’ concerns and effectively monitor poor care including “false assurances” by regs inc. CQC
There was a ‘culture of reluctance’ to perform caesarean sections & together with ineffective fetal monitoring poor maternity care @sathNHS resulted in “many babies dying during birth or shortly after birth”
Trust had a “tendency to blame mothers” for poor outcomes, in some cases “even for their own deaths”, the review says
Final report issues more than 60 local actions for @sathNHS & says there was a ‘them and us’ culture between midwifery and obstetric staff
15 immediate and essential actions for all maternity services in England also identified - @DOckendenLtd’s report says @NHSEngland must commit to multi-year investment plan to ensure provision of well-staffed safe workforce
Acknowledges £127m sum announced by NHSE last week but says this “still significantly short” of £200-£350m recommended by @CommonsHealth last year
Boards must work with maternity depts to develop regular reports ensuring improvement plans & actions - and every trust should have patient safety specialist in maternity
Must be mandatory joint learning when mother dies & bereavement services must be available every day of week, not just Mon-Fri
In update @DOckendenLtd says: “A death of a mother or baby, or a birth incident which results in an injury should never be ignored”, adds “there should never again be a review of this scale, in both numbers, and the length of years across which these concerns remained hidden”
Says “what is astounding is that for more than two decades these issues have not been challenged internally and trust was not held to account by external bodies” - systemic change needed locally & nationally to ensure professional, compassionate care & teams/boards accountable
Asks @DHSCgovuk @sajidjavid to back a working maternity group independent of the maternity transformation programme - more @HSJnews shortly 
Story now leading @HSJnews - expect more throughout the day hsj.co.uk/patient-safety…
Eight external bodies checked on trust - yet while external reports often indicated need for governance improvements - this didn't happen. @DOckendenLtd tells #ockenden2 briefing: "The trust was of belief its maternity services were good. They were wrong."
She adds: "Wasn't just the maternity unit in chaos and under pressure. This was a whole organisation where it was difficult to find an area which wasn't under pressure"
Full report now live: donnaockenden.com/wp-content/upl…
This is very much not a historic problem - staff told @DOckendenLtd in recent weeks - with info added in very final days before publication - staff members described a ‘clique' on the labour ward at the trust with a culture of undermining and bullying
Louise Barnett @sathNHS CEO says in statement that org “owes it to families we failed” to make changes 👉🏻 sath.nhs.uk/news/statement…
At around 1pm today @sajidjavid due to make statement @houseofcommons about #ockendenreport commonsbusiness.parliament.uk/document/55871…
V worrying that in final weeks leading up to #ockendenreport a number of staff withdrew cooperation - main reason cited was “fear of being identified” - just over 100 staff contributed in the end
It’s been a harrowing day for many families - Sonia Leigh, whose daughter Kathryn died in 2000. She was just 21 minutes old. Sonia tells me there needs to be an “open and honest” health authority where staff feel they can speak up without losing their jobs
She says she was made to feel Kathryn’s death was her fault by clinicians at Shrewsbury as she’d said she wanted a natural birth. She was left in labour overnight before needing an emergency caesarean - the experience left her with PTSD which went undiagnosed for years
In @DOckendenLtd’s local actions for learning it’s suggested that a clinical psychologist should be employed to support the maternity department going forwards
Families I’ve spoken to today say trust leadership has been v quiet in recent years - we @HSJnews are chasing an interview with CEO Louise Barnett - lots to digest in #ockendenreport re recent problems
Further into #ockendenreport from interviews with senior staff from CCGs in post from 2013-2020 review team was told commissioners had concerns about length of time that serious incidents took to be reported
They were told by a contributor to such reviews that “they seemed to take a long, long time to happen and there was an evasiveness around how the learning from those reviews was shared”
Review team believed that trust board & CCGs were “reassured” rather than “assured” over governance and safety within @sathNHS maternity services
As @hergehound5 says this is watershed moment for the NHS - with failures still being reported at Shrewsbury and others like East Kent & Notts yet to report full findings - surely now is time to finally act?
‘Ideologically driven’ NHSE maternity model causing national tension, reports @HSJAnnabelle - follows @DOckendenLtd call in #ockendenreport to suspend continuity of carer in all trusts until “robust evidence” exists to support its reintroduction hsj.co.uk/quality-and-pe…
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