Shropshire maternity scandal: Dates set for some improvements 'over-ambitious' claims report

Dates set for some improvements to Shropshire's scandal-hit maternity services were “over-ambitious” and “more realistic delivery dates” will need to be agreed, a report says.

The Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust (SaTH) published its first report in December.

Based on 250 reviews of cases of mother and baby injury or death, it issued 27 “must-do” recommendations for the trust itself and 25 more actions for all English maternity providers.

In a report, SaTH Nursing Director Hayley Flavell writes that 20 out of the total of 52 actions have been delivered, with just four considered “off-track”.

She and says the trust will try to establish “more realistic delivery dates” for the rest this month.

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Launched in 2017 and led by maternity expert Donna Ockenden, the review is due to examine nearly 2,000 cases by its expected conclusion later this year.

The “emerging findings” report said some mothers were blamed for the loss of their babies, medics and the trust used “inappropriate” language towards grieving families and some deaths went “uninvestigated”.

In her report, which will be discussed by SaTH’s board tomorrow Mrs Flavell writes: “There is a need to review the expected delivery dates for some of the first Ockenden Report actions.”

Reasons for this include “an enthusiasm to deliver the required actions as soon as possible”, something she admits was “slightly over-ambitious for some of the actions”.

“The trust now has a deeper understanding of all the actions and the supportive ‘sub-actions’ for each,” she adds.

“The team is clear that these actions all need to be delivered fully and thoroughly.”


Mrs Flavell adds that there are outstanding “resource issues” and a new patient information system is not in place yet.

“Work will take place during May to try and provide more realistic delivery dates and also to populate all the required dates on the action plan,” she writes.

“In summary, good progress is being made with the action plan overall and the governance and assurance around this is becoming more robust and clearer.”

Ms Ockenden’s report required SaTH to “appoint a dedicated lead midwife and lead obstetrician” to focus on and improve bereavement care within the maternity service.

Ms Flavell’s report says this has not happened yet because “the funding for the posts in question has not yet been approved”.

A new delivery date of July 31 – four months later than originally planned – is proposed, but she adds that “the bereavement service is nonetheless being delivered, with specialist midwives in place and consultants making time to provide this form of care”.

Ms Ockenden’s report also required that all families with babies born on a local neonatal unit and needing intensive care should have a “clearly documented early consultation” with a specialist unit.

This is also delayed until July, Ms Flavell’s report says, due to an “apparent contradiction” between Ms Ockenden’s recommendation and British Association of Perinatal Medicine guidance.

The review team and an expert neonatologist will be consulted to resolve this, it adds.

Two more actions – from the 25 directed at maternity providers nationwide – are classed as “off-track”, Ms Flavell adds.

One of these, relating to serious incident reports, is not yet classed as completed because of “not enough evidence of transparency”, and the other, surrounding women’s participation in decision-making, because the Maternity Transformation and Assurance Committee “are not satisfied we have yet done enough to hear from women whether they feel that have all the information they require”.

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