Findings, Conclusions and Essential Actions from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust

Midlands

Published 30 Mar 2022

Trust Shrewsbury and Telford NHS Trust

Investigator Donna Ockenden

Independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, commissioned by the Secretary of State for Health and Social Care in 2017. Led by Donna Ockenden (senior midwife). Final report published 30 March 2022. Reviewed 1,486 families over 20 years (2000–2019), finding repeated failures in care involving three maternal deaths and multiple baby deaths and brain injuries. Identified a culture of not listening to women, poor teamworking, and failure to learn from adverse events. Made 15 Immediate and Essential Actions (IEAs) applicable to all NHS trusts, and 64 Local Actions for Learning specific to the trust. Government accepted all national recommendations on publication and committed £127m to maternity services improvement.

Report PDF NHS England Source

Acceptance Status

Accepted 15

Total Recommendations 15

About this data

Acceptance Status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

Recommendations (15)

IEA 1

Accepted

Recommendation

Essential action – financing a safe maternity workforce: The recommendations from the Health and Social Care Committee Report: The safety of maternity services in England must be implemented. Essential action – training: We state that the Health and Social Care … Read more

Secretary of State Sajid Javid, oral statement to the House of Commons, 30 March 2022: "The local trust, NHS England, and the Department of Health and Social Care will be accepting all 84 recommendations." NHS England committed to a renewed delivery plan reflecting the IEAs.

IEA 10

Accepted

Recommendation

Women who choose birth outside a hospital setting must receive accurate advice with regards to transfer times to an obstetric unit should this be necessary. Centralised CTG monitoring systems should be mandatory in obstetric units.

IEA 11

Accepted

Recommendation

In addition to routine inpatient obstetric anaesthesia follow-up, a pathway for outpatient postnatal anaesthetic follow-up must be available in every trust to address incidences of physical and psychological harm. Documentation of patient assessments and interactions by obstetric anaesthetists must improve. … Read more

IEA 12

Accepted

Recommendation

Trusts must ensure that women readmitted to a postnatal ward and all unwell postnatal women have timely consultant review. Postnatal wards must be adequately staffed at all times.

IEA 13

Accepted

Recommendation

Trusts must ensure that women who have suffered pregnancy loss have appropriate bereavement care services.

IEA 14

Accepted

Recommendation

There must be clear pathways of care for provision of neonatal care. This review endorses the recommendations from the Neonatal Critical Care Review (December 2019) to expand neonatal critical care, increase neonatal cot numbers, develop the workforce and enhance the … Read more

IEA 15

Accepted

Recommendation

Care and consideration of the mental health and wellbeing of mothers, their partners and the family as a whole must be integral to all aspects of maternity service provision. Maternity care providers must actively engage with the local community and … Read more

IEA 2

Accepted

Recommendation

All trusts must maintain a clear escalation and mitigation policy where maternity staffing falls below the minimum staffing levels for all health professionals.

IEA 3

Accepted

Recommendation

Staff must be able to escalate concerns if necessary. There must be clear processes for ensuring that obstetric units are staffed by appropriately trained staff at all times. If not resident there must be clear guidelines for when a consultant … Read more

IEA 4

Accepted

Recommendation

Trust boards must have oversight of the quality and performance of their maternity services. In all maternity services the Director of Midwifery and Clinical Director for obstetrics must be jointly operationally responsible and accountable for the maternity governance systems. Read more

IEA 5

Accepted

Recommendation

Incident investigations must be meaningful for families and staff and lessons must be learned and implemented in practice in a timely manner.

IEA 6

Accepted

Recommendation

Nationally all maternal post-mortem examinations must be conducted by a pathologist who is an expert in maternal physiology and pregnancy related pathologies. In the case of a maternal death a joint review panel/investigation of all services involved in the care … Read more

IEA 7

Accepted

Recommendation

Staff who work together must train together. Staff should attend regular mandatory training and rotas. Job planning needs to ensure all staff can attend. Clinicians must not work on labour ward without appropriate regular CTG training and emergency skills training. Read more

IEA 8

Accepted

Recommendation

Local Maternity Systems, Maternal Medicine Networks and trusts must ensure that women have access to pre-conception care. Trusts must provide services for women with multiple pregnancy in line with national guidance. Trusts must follow national guidance for managing women with … Read more

IEA 9

Accepted

Recommendation

The LMNS, commissioners and trusts must work collaboratively to ensure systems are in place for the management of women at high risk of preterm birth. Trusts must implement NHS Saving Babies Lives Version 2 (2019).