MP calls for 'safer and more compassionate' maternity care after 'devastating' Ockenden report

Telford MP Lucy Allan spoke in parliament after the Ockenden Report was published today. The inquiry, led by maternity expert Donna Ockenden, revealed that at least 201 babies and nine mothers could have been saved if they had received better care at Shrewsbury and Telford Hospitals Trust.

Addressing Prime Minister Boris Johnson, Ms Allan said: "The report makes for devastating reading, more so because women's voices were ignored.

"My constituent, Hayley Matthews, begged staff for a C-section throughout her 36-hour labour, but was forced into a natural birth. Her son Jack arrived blue and floppy and within hours of his birth he tragically died. Will the Prime Minister join me in offering heartfelt sympathies to all families affected and also grateful thanks to the 1,862 women who shared their experiences with the Ockenden Review to ensure that maternity care is safer, kinder and more compassionate for the women that come after them?"

Mr Johnson replied: "I think everyone will thank the women concerned for taking up the issue in the way that they have. We all extend our heartfelt sympathies to the victims and their families for what they have suffered. It is very important that people get the answers that they deserve, but also that we have the right approach to this issue in the future. That's why we're investing very substantially in maternity services, and very substantially in midwives and in our NHS altogether."

Other county politicians reacted to the damning report, which found leaders and midwives were determined to keep Caesarean section rates low, despite the fact this repeatedly had severe consequences.

The inquiry is the largest ever into a single service in the history of the health service and has wide-ranging implications for the maternity in the NHS.

Ludlow MP and former Health Minister Philip Dunne said: "I would like to add my thanks to Donna Ockenden and her team of over 90 experienced clinicians, who have so painstakingly reviewed 1,592 clinical incidents going back many years. This must have been harrowing for them and for all the families so tragically affected.

"In particular I must praise the courage and tenacity of Rhiannon Davies and Richard Stanton, who were my constituents when they lost their baby Kate in truly awful, and tragically avoidable, circumstances.

"It was they who kept pressing for answers from Shrewsbury and Telford Hospital NHS Trust, which led me to take them to meet the Health Secretary at the time, Jeremy Hunt, who launched this inquiry.

"The review identifies a series of failings, from prevailing culture across the medical profession to promote natural births, to failings within the Trust which seemed to prioritise targets over the needs of individual mums and then to have an inadequate system for investigating and explaining what went wrong.

"I have discussed the Ockenden review with the chief executive of SaTH, and senior doctors and nurses, who claim to have implemented 100 per cent of the initial report’s recommendations where SaTH is the lead organisation. I want to see this verified, as there remain serious management issues to be addressed from staff feedback to the Ockendon team. But the feedback SaTH have gathered from women who have given birth recently shows significant improvement is already taking place.

"It is vital the recommendations from this review are acted upon, not only by SaTH, but across maternity systems in NHS England. The Ockendon report must resonate for years to come, in better, safer services for mums not just in Shropshire, but across the country.”

Shrewsbury MP Daniel Kawczynski said: "The accounts of the parents are truly heart breaking and the brave staff members who came forward gave very concerning accounts.

"One of the central issues surrounding the failures of the Shrewsbury and Telford hospital is that there was a drive by the NHS, the Royal College of Midwives (RCM), Royal College of Obstetricians and Gynaecologists (RCOG), and National Childbirth Trust for mothers to have a natural birth, seemingly at all costs. The lowest percentage of caesarean deliveries by the Shrewsbury and Telford Hospital was incorrectly applauded and regarded as a laudable achievement. This was accompanied by a grave lack of empathy for mothers, a pattern of consistent disregard for the families’ concerns and, when there was medical intervention provided, it was often tragically too late.

"I mention the staff who came forward and characterise them as brave. It is very concerning that it has been reported that staff members often felt afraid to voice their concerns or were worried of being reprimanded for giving accounts to Ms Ockenden and her team.

"When Ms Ockenden began this investigation in 2017, her team were initially given 23 cases. Today, we find a total of 1,486 families within the report and that shockingly 210 deaths could have been avoided: 201 babies and nine mothers.

"There was a failure to assess risk, a shifting of blame from the Trust to the mothers and a failure to take grasp key opportunities for change. This is in addition to a real concern that even after the 2020 initial report, families are still coming forward to the investigative team. I agree with Ms Ockenden that the high staff turnover due to the conditions on the ward cannot be fixed with constant recruitment. What is needed is a fundamental change in the way the hospital and specifically the maternity ward is managed.

"My peers, fellow Shropshire MPs and I have been in regular calls with the hospital and we have been given a detailed account of the changes that the hospital is making. We are assured that there have been major changes to the culture of care given by staff, and importantly, the investigative procedures which will ensure that cases raised are not only handled by the hospital but by an unbiased board. 100 per cent of the actions recommended by the first report have been actioned: 67 per cent are fully in place and evidence is available, 19 per cent delivered but evidence is being gathered and 14 per cent on track to being delivered.

"I cannot begin to imagine the severe trauma these families have gone through. In some cases, their children have died and in other cases their children now live with the lifelong consequences of a lack of care that should be basic and second nature to a maternity ward.

"With this report now in hand, I will be working with my peers to see absolute and real change to the hospital."

Leader of Telford & Wrekin Council, Councillor Shaun Davies said: "My heart goes out to the courageous families who shared their harrowing experiences with Donna Ockenden about the failures in maternity care at Shrewsbury and Telford NHS Trust. Without their significant contributions the report would not have the necessary impact to affect change. Their bravery in coming forward is a tribute to the babies they have loved and lost and others who have endured life changing injuries.

"The publication of this report is a watershed moment not only for the NHS but crucially for our local families who wanted to understand what happened to them and to ensure the future safety of maternity services in the region and beyond.

"I’m a local dad, to a child who was born in the care of the Trust just over five years ago and I’ve heard first hand perspectives from parents who have shared their own, deeply personal and moving stories. I am very conscious of the enduring distress and pain felt by many families.

"I am in regular touch with senior leaders at SaTH, seeking assurances that they are implementing changes. I do recognise there has been considerable strides in maternity care since the interim report and there are many members of staff as SaTH who work extremely hard to make sure parents and babies now have a positive experience. It is clear however that the Trust requires significant backing and investment into maternity, A&E and other services. For far too long, the much needed funding and resources hasn't arrived. Telford and Wrekin Council wants the best possible healthcare for our residents; we will continue to offer and provide support and challenge to the Trust."