The long-awaited report of the independent review into maternity and neonatal services at Nottingham University Hospitals NHS Trust has now been published. The review, carried out by senior midwife Donna Ockenden, looked into 2500 cases between 2012 and 2015, making it the largest maternity review in NHS history. She was previously involved in the review of maternity care at the Shrewsbury and Telford Hospital NHS Trust and is due to complete a future review into care at Leeds Teaching Hospitals NHS Trust.
The review has found that hundreds of babies and mothers were harmed or died due to deep systemic failures in maternity care. It identified 520 cases of mothers and babies, where there was a potentially avoidable outcome. It also found that different care may have altered the outcome for 260 babies who died or were harmed. Of this number 105 babies suffered serious injury, and 155 babies died.
There were numerous failings in care at the trust, including an overwhelming failure to listen and act on the concerns raised by mothers and fathers. Also, that there were unsafe staffing levels, a culture of bullying raised by staff, and a lack of management and leadership. There were also cases identified of poor post death care and bereavement support.
What now?
The report has set out a number of actions points to be implemented in both Nottingham and across England to improve maternity care and safety. Some of these include improvements to risk management and monitoring throughout pregnancy, training, staffing levels and incident investigations.
Donna Ockenden has confirmed she will continue to work with the trust over the next 18 months to 2 years to ensure the improvements are made and learning takes place.
In response, the government have committed to extending Martha’s Rule to all maternity settings within the NHS. Martha’s Rule is a patient safety initiative that was introduced following the death of 13-year-old Martha Mills. The initiative allows patients and their family to request an urgent second opinion if they feel a deterioration in condition is not being addressed. The government has also announced that they are going to look into whether secondary victims of maternity trauma, such as fathers and partners, will be able to bring their own claims against trusts.
The impacted families are now calling for a statutory public inquiry, meaning it would be mandatory for those involved to give evidence, and allowing for full accountability. This follows reports that senior staff at the trust failed to take part in the Ockenden review.
Ally Taft, Head of Clinical Negligence at Medical Accident Group, said “Sadly this is yet another review which raise concerns about a maternity unit and we see the same problems being identified across the country, which can lead to devastating consequences. I hope that changes can be implemented that will improve the care provided to mothers and babies at the trust”
