James Watts, consultant in anaesthesia and critical care medicine at East Lancashire NHS Trust discusses the Ockenden Report and the role of the obstetric anaesthetist.
In 2016, Donna Ockenden, former Clinical Director of Midwifery at the London Strategic Clinical Network at NHS England, was commissioned by Jeremy Hunt, then Secretary of State for Health, to Chair an Independent Review into maternity services at the Shrewsbury and Telford Hospitals NHS Trust (SaTH) following a series of well publicised concerns. These concerns included excess mortality of both babies and mothers.
In the end, the initial review committee considered 23 deaths; was later widened to consider 60 patients; and then in 2019 revised again by the new Secretary of State, Matt Hancock, to consider hundreds of cases where care was feared to have been substantially poor.
Her final report was published in 2022, having considered 1486 family experiences of 1592 reported incidents that had occurred between 1973 and 2020; 84 staff questionnaires; and 60 staff interviews. Notably, some staff asked their comments to be deleted from the report due to fears they would be identified and targeted by management. (1)
Common themes identified were missing warning signs, failure to act appropriately when they were detected and failure to recognise or learn meaningfully from these issues. The sheer number of incidents occurring should have rung alarms, but red flags were missed because of repeated turnover at senior management level. It is reported that the Obstetric department rejected the findings of an RCOG review and resorted to defensive silo working. A former executive board member reportedly said it was a ‘…Republic of Maternity, where, often, the maternity service seemed to consume its own smoke, and didn’t like having oversight by the corporate team…there was a disconnect both ways actually, I believe, from the corporate team to maternity and maternity to the corporate team’. This meant that the recommendations of external reviewers (and there were several before the crisis broke) could not be implemented.
The report itself said:
‘….throughout the review period staff were overly-confident in their ability to manage complex pregnancies and babies diagnosed with fetal abnormalities during pregnancy. There was sometimes a reluctance to refer to a tertiary unit to involve specialists such as paediatric surgeons and geneticists in care….the neonatal unit at Royal Shrewsbury Hospital continued to work as a neonatal intensive care unit for many years after it had been re-designated as a local neonatal unit. … Internally, within maternity services at the Trust women were frequently not referred to or discussed with colleagues from the wider multidisciplinary team. It has been observed that there were repeated failures to escalate concerns in both antenatal and postnatal environments…… The review team has also heard directly from staff that there was a culture of ‘them and us’ between the midwifery and obstetric staff, which engendered fear amongst midwives to escalate concerns to consultants. This demonstrates a lack of psychological safety in the workplace, and limited the ability of the service to make positive changes.’
The report comes on the back of other reviews of NHS maternity services including Northwick Park (10 maternal deaths between 2002 and 2005 with causes including poor leadership, toxic staff culture and staff shortages) (2); and Morecambe Bay Trust ( ‘the Kirkup report’: avoidable deaths of 11 babies and 1 mother between 2004 and 2013 due to poor working relationships between specialties and a toxic over promotion of natural childbirth by a cadre of midwives (3)
Rhiannon