The Shrewsbury and Telford Hospitals NHS Trust

The Shrewsbury and Telford Hospital NHS Trust (SaTH) has set up a new committee to ensure that all the essential actions for the Trust that were outlined last year, in the first report of the Ockenden Review,  – a review of maternity services at SaTH –  are being implemented.

The committee titled the ‘Ockenden Report Assurance Committee’ (ORAC) held its first meeting on Thursday 25 March between 8.30 -11am. The ongoing meetings will be used to track the Trust’s progress on taking forward the essential actions of the Ockenden Review. 

The meetings will be held in public to ensure transparency and with COVID restrictions still in place, people will also be able to watch the meetings online.

Committee members will include the Trust’s Chief Executive, Louise Barnett, and representatives from partner organisations, including Shropshire and Telford and  Wrekin Maternity Voices Partnership, Clinical Commissioning Groups, and Healthwatch. 

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Please see below a short video recorded to capture family questions that were submitted to the Maternity Review Team following the publication of our first report

The West Midland Ambulance Service (WMAS) had their Board of Directors meeting on 27th January. At the meeting they presented a report which outlined the assurance required to ensure they are delivering the best possible care, as well as learning from the Ockenden report to identify any further actions that WMAS can take to improve care to women who are in labour and who may have complications of labour.

They note that “although, it may appear that the Ockenden report is more applicable towards hospitals, as an emergency ambulance service providing pre-hospital maternity care, it is essential we respond to at least 4 of the 7 Immediate and Essential Action’s (IEA) highlighted within the Ockenden Report which apply to our trust. In addition, there are generic relevant issues that are highlighted in the report and these are highlighted in the enclosed action plan.”

Attached are the papers from the board meeting, please note it is 208 pages long. The section related to the Ockenden report starts on page 37. It also contains their action plan in relation to the Ockenden Report (2020) WMAS Review of Immediate and Essential Actions and Ockenden Report (2020) WMAS Review of Relevant Issues in Report.

Read papers from the board meeting here  

The Government has announced a £500,000 maternity leadership programme to train senior maternity and neonatal leaders. This follows on from the issue of leadership being identified as a key factor in Donna Ockenden’s independent review into cases of neglect and preventable baby deaths at Shrewsbury and Telford NHS Trust.

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Please read letter  from England’s Chief Midwifery Officer and National Clinical Director for Maternity regarding next steps following the publication of our first report on the 10^th December 2020. 

Read Letter Here

Please read press release released on the 12^th January 2021 from the Department of Health and Social Care concerning maternity leadership training following on from our first report published 10^th December 2020

Read Press Release Here

Minister of State for Patient Safety Nadine Dorries MP Statement: Publication of the findings of the Ockenden Review (10^th December2020)

Link to video statement in Parliament 

Please read letter from Chief Executive, Executive/National Director and National Medical Director for NHS England and NHS Improvement regarding next steps following the publication of our first report on the 10^thDecember 2020. 

Today, 15^th December 2020 as the Chair of the Independent Maternity Review at the Shrewsbury and Telford Hospital NHS Trust Donna Ockenden was asked to appear before the  Health Select Committee  at  The Houses of Parliament. Donna was invited to answer questions from the Select Committee on our first report published on Thursday. Donna’s piece runs from 0952hrs   to 1027 hrs  but before and after that there is some very interesting information on maternity services that may be of interest. 

Link to Parliamentlive.tv 

Thursday, 10th December 2020, marks the launch of the first report of the independent review into maternity services at the Shrewsbury and Telford Hospital NHS Trust. The report outlines the local actions for learning for the Trust and immediate and essential actions for the Trust and wider system that are required to be implemented now to improve safety in maternity services for the Trust and across England.Read the report here

Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden.

Read statement from RCM   
Read statement from RCOG 

These ‘essential and immediate actions’ originate from The Ockenden Review’s preliminary analysis of  250 cases of concern, including the original 23 cases that led to the review.  A total of 1,862 cases will be considered by the review’s conclusion. 

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“It is shocking that so many babies have died at Shrewsbury and Telford Hospital Trust. We are here to offer bereavement support to all those parents and families affected, who will be going through unbearable pain following their loss”.

Read full statement from Clea Harmer, Chief Executive SANDS 

Group B Strep Support has responded to the interim findings of the independent review of maternity services at Shrewsbury and Telford Hospitals (SATH) NHS Trust by a team led by midwifery expert Donna Ockenden, published today.

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Today’s report from the Ockenden Review of maternity care at Shrewsbury and Telford Hospital NHS Trust makes for shocking reading. It is clear that good practice was frequently not followed. 

Read more 

Professor Ted Baker, Chief Inspector of Hospitals, said:  
“The death or injury of a new baby or mother is a devastating tragedy and something that everyone working in the health and care system must do all they can to prevent.   
“The emerging findings from Donna Ockenden’s review make for difficult reading. Limited oversight of risk, insufficient safety training for staff, poor communication with families, and a lack of robust investigation or learning when errors were made. Sadly, these are all themes that have been identified before, but yet again it has taken the repeated persistence of campaigning families and patients to bring them to the fore.  

“The continued national focus on the safety of maternity services is welcome – and we are seeing some positive change. However, the progress made does not yet meet the scale of the challenge.  

“As we set out in our Getting Safer Faster briefing earlier this year, there needs to be concerted national action and accelerated efforts to ensure that improvements in safety are achieved with the urgency required.  A major factor in this is the need to drive a change in culture that means the voices of staff, patients and their families are listened to and acted on. Without this shift we will not move forward. 
 “We welcome the recommendations set out by Donna Ockenden and her team and will monitor their implementation by the Trust, as well as working with the Department of Health and Social Care, NHS England/Improvement and wider system partners to play our part in supporting implementation. 

Assistant Chief Constable for West Mercia Police, Geoff Wessell, said: “Our investigation is running concurrently to the Ockenden Review and we have had sight of the report that has been released today. 

“We are mindful that the families involved with the review have waited patiently for the initial learning actions outlined in the report. I want to reassure them, and the wider community, that our investigation will, in no way, impede the work of the Ockenden Review or prevent the actions outlined in today’s report from being implemented. 

“Our investigation into maternity services at the Trust remains ongoing and, as such, we are not in a position to release any further information at this time. When there is an update we can provide we will share this with the families involved first and foremost and then to the wider public.”

The Shrewsbury and Telford Hospital NHS Trust response to Donna Ockenden’s first report following the Independent Review of Maternity Services (10^th December2020)

Link to video statement given by the Chief Executive

We now have a provisional date of the 10th December, subject to the Parliamentary timetable permitting,  for the first report into maternity services at the Shrewsbury and Telford NHS Trust (SaTH). This will be an emerging findings report and will include ‘Essential and Immediate Actions’,  as a result of our review of a selection of 250 cases of concern, which include the original 23 cases which initiated this independent maternity review.  The emerging findings report will include ‘Essential and Immediate Actions’ which we feel are necessary to ensure safe practice in maternity services at SaTH and will make a difference to the safe provision of maternity services elsewhere.