Urgent and sweeping modifications are needed in all English hospitals to prevent avoidable infant deaths, stillbirths and neonatal brain damage, a damning report into among the biggest scandals in the history of the NHS has actually said.
It uncovers a pattern of grim failures at Shrewsbury and Telford medical facilities (SaTH) that led to the deaths and harming of mothers and children from 2000-2019. These included a lethal reluctance to conduct caesarean areas; a propensity to blame mothers for problems; a failure to handle intricate cases; an absence of specialist oversight, and a “deeply distressing lack of compassion and compassion”.
The review information a series of instant actions and “should do” recommendations for all medical facility trusts to improve maternity safety “at rate”. These include formal danger assessment at every antenatal contact, twice-daily consultant-led maternity ward rounds, women and family advocates on the board of every NHS trust, and the visit of devoted lead midwives and obstetricians.
The independent review, by a team led by midwifery expert Donna Ockenden, found 1,862 serious events consisting of hundreds of baby deaths and an unusually high variety of maternal deaths, mainly in between 2000 and 2019.
In June West Mercia cops released an examination into the worst of the cases.
A medical evaluation of a choice of 250 of the cases triggered Ockenden to lay out Thursday’s emerging findings report so that action can be taken now prior to the complete report is completed. When completed the review is most likely to be the largest in NHS history.
” We owe it to the 1,862 families who are adding to this review to bring about rapid positive and sustainable change across the maternity services at SaTH,” states the interim report.
It requires 27 local actions for finding out and seven instant and important actions for all maternity services “to be implemented now and at pace”.
Other recommendations include greater oversight of maternity care by senior physicians, ringfenced financing for maternity training and the development of local specialists in maternal medicine.
The failings identified at SaTH represent mounting issues about security and possibly avoidable deaths at other maternity services. In September, Prof Ted Baker, the chief inspector of hospitals, admitted to MPs that 38% of maternity services were considered to require improvement for patient security and some might get even worse.
Ockenden pleaded with health centers to comprehend the urgent need to enhance security for mothers and infants. She said: “We implore maternity services across England to carefully consider this very first report and to make ambitious strategies to ensure timely execution of these local actions for learning and instant and essential actions occurs.”
The Ockenden review was bought in 2017 by the then health secretary, Jeremy Hunt, after the families of 2 children, Kate Stanton-Davies and Pippa Griffiths, who passed away under the trust’s care, raised issues about their cases and 21 others.
Ockenden commemorated the parents of those infants, who she said had tried to raise severe issues about maternity care at the trust and “who have informed us they were not listened to”. She said: “Kate and Pippa’s parents have actually shown an unrelenting dedication in guaranteeing their children’ brief lives made a distinction to the security of maternity care.”
Rhiannon Davies, who lost her child Kate in 2009, stated: “There is an ingrained issue in maternity, a deeper-seated issue in midwifery and a hazardous issue at the heart of SaTH’s particular midwifery and obstetric services.”
She included: “Ladies are not aware of the threats they and their child face during labour and birth. And whilst no one wishes to feel fear and be disempowered through angst, everyone deserves openness and the accessible information to assist them make an informed option.
” In regards to midwifery, there is a culture of normal birth at any expense. This has pervaded for decades. It originates from the ideology behind current midwife training. That needs to change.”
Nadine Dorries, the health minister responsible for client safety and maternity, said: “I anticipate the trust to act on the recommendations right away, and for the wider maternity service right across the nation to think about essential actions they can require to improve safety for moms, children and households.
” This federal government is absolutely committed to patient security, removing avoidable damages and making the NHS the best place in the world to give birth. We will work closely with NHS England and Improvement, as well as Shrewsbury and Telford medical facility NHS trust to think about next actions.”
Louise Barnett, SaTH’s chief executive, stated it would carry out all the suggestions in full. She stated: “On behalf of the entire trust, I want to say how very sorry we are for the discomfort and distress that has been triggered to mothers and their families due to bad maternity care at our trust.
” I can ensure the ladies and families who utilize our service that if they raise any concerns about their care they will be listened to and action will be taken.”