Bernadette McGhie comments on the first Ockenden report on emergency findings and recommendations from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust published on 10 December 2020.
The Ockenden report was first commissioned by former Secretary of State, Jeremy Hunt. This interim report has been published now because the chair, Donna Ockenden, who started work on the review based on 23 cases, had found that the number of cases has increased to 1,862.
Given the extent of the concerns and themes raised in her review of 250 cases to date, she has set out those emerging findings and themes with her recommendations. She has outlined learning and action points to assist the trust with making immediate and significant improvements to the safety and quality of their maternity services as well as immediate and essential actions to improve care and safety in maternity services.
In essence, the aim of the report is not simply to condemn past care and management at Shrewsbury but to inform all maternity services with the overriding objective of improving maternity care and safety for all. It is all very well for us to deem the practice and governance at Shrewsbury as scandalous but we know from past experience that this is not an isolated issue. We can demonstrate our horror and disapproval but all too often the underlying causes simply re-occur elsewhere until the next scandal is identified. There have been reports previously relating to other trusts and the saddest thing of all is that for those of us on the outside once the initial furore has ended we can move on.
From my experience as a clinical negligence lawyer specialising in maternity cases as well as my previous experience as a paediatric nurse, I know only too well that for those families involved the memories and physical and mental hurt does not go away. If we cannot learn from such reports then we are letting down future generations. We are also letting down those amazing maternity teams and individual practitioners who work so hard to provide an excellent safe, happy and seamless experience for mothers and babies.
I genuinely hope and believe that there is currently a mindset to learn from this exposure and I hope that this encourages staff and patients alike to feel empowered to speak out where they have concerns about care and safety. We can learn from past mistakes and we must. The future can be bright for Shrewsbury and all other maternity services.