Trusts must maintain a clear escalation policy for when maternity staffing falls below the minimum threshold, the Ockenden report published today has concluded.
The report identified safe staffing, escalation and accountability, workforce planning and sustainability, and mandatory training with colleagues, as part of 15 areas for ‘immediate and essential action’ to improve care and safety in maternity services across England.
It called on NHS England to commit to a multi-year investment plan in workforce – including a recruitment and retention drive – with minimum staffing levels agreed and adhered to nationally.
Senior midwife Donna Ockenden had examined cases involving 1,486 families affected by a maternity scandal at the Shrewsbury and Telford NHS Trust. The Ockenden review was first launched in 2017 with an interim report published in December 2020.
The latest report looking at a series of serious and deadly incidents in Shropshire found a strong of ‘repeated failures’ spanning two decades.
There were hundreds of cases where the Trust failed to undertake serious incident investigations, with even cases of death not being examined appropriately, it concluded.
Ms Ockenden said: ‘The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved.
‘There was a tendency of the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths…. Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide.’
Sajid Javid, health and social care secretary, said: ‘Donna Ockenden’s report paints a tragic and harrowing picture of repeated failures in care over two decades, and I am deeply sorry to all the families who have suffered so greatly.
‘Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.’
This comes after NHS England announced a £127m investment in maternity services earlier this month, although this is short of the £200 to £350m recommended by the Health and Social Care Committee in June 2021.
The 15 ‘immediate and essential action’ areas identified by the report include:
• NHS England must commit to a multi-year investment plan to ensure the provision of a well-staffed workforce with appropriate minimum staffing levels agreed nationally.
• Sufficient protected time must be allocated for training across all maternity specialisms including routine refresher courses as well as multidisciplinary team training.
• A clear escalation and mitigation policy when agreed staffing levels are not met.
• Trust Boards must work with their maternity departments to develop a process of regular reports and reviews to ensure improvement plans and actions take place.
• Meaningful incident investigations with family and staff engagement and practice changes introduced in a timely manner.
• Mandatory joint learning across all care settings when a mother dies, with post-mortem examinations conducted by expert pathologists in maternity.
• Care of mothers with complex and multiple pregnancies must be provided by specialists.
• Ensuring the recommendations from the 2019 Neonatal Critical Care Review are introduced at pace, such as at least 85% of births at less than 27 weeks taking place in a maternity unit with an onsite NICU where appropriately trained consultants and staff are available 24/7.
• All trusts must develop a system to ensure consultant review of all postnatal readmissions, and unwell postnatal women, with appropriate staffing levels to deliver this.
• Bereavement services must be available every day of the week, not just Monday to Friday and staff must be trained to take post-mortem consent.