Yesterday, Wednesday 30th March, was a significant day for those affected by the maternity scandal at The Shrewsbury and Telford Hospital NHS Trust (SaTH), as the long awaited Ockenden Report was finally published. Contained within its 234 pages were findings, conclusions and action points to improve care and safety in maternity services across England.
In total over 1592 clinical incidences, involving mothers and babies, were reviewed as part of the inquiry. Spanning over 20 years, and encompassing more than 200 deaths, the report focused on “a trust that failed to investigate, failed to learn and failed to improve.”
There were several different areas for concern. These included staffing, incidence escalation, training, accountability, clinical governance, investigation procedures and family support. The review highlighted a culture of not investigating mistakes, with hundreds of instances where SaTH failed to appropriately examine deaths or undertake serious incident investigations with mistakes being “inappropriately downgraded”.
The Ockenden Inquiry found that hundreds of families were failed, mistakes were made and many of the deaths were avoidable. In its conclusions it raised 15 areas for ‘immediate and essential action’ in England maternity care, with a further 60 local actions for learning for SaTH.
Kiran Jalota, Head of Medical Negligence and Personal Injury, said. “The inquiry was a much-needed wake up call to avoid further tragedies happening in the future. It highlighted the need to remove a blame culture and make it easy for people to speak openly. It was shocking to hear that both doctors and midwives were silenced and told there would be professional consequences if they cooperated with the inquiry.”
Kiran continued. “What is perhaps most extraordinary of all is the courage and tenacity of families who, despite their pain, continued to campaign so that their stories and the truth about what happened could finally be heard. I know that the publication of a report cannot turn the clock back, but it will hopefully prevent others from experiencing similar feelings of loss and anger.”
Kiran concludes. “I sincerely hope that the changes at both a local and national level will ensure that care provided to families is always professional and compassionate. It is important that all staff, regardless of whether they are on the wards or on the board, are aware of what is going on and accountable for the values and standards that they have been trusted with upholding.”
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At Alsters Kelley, our approach is personal, sensitive, and caring. We understand you may have already suffered harm in the hands of those you put your trust in, which is why we put you at the heart of everything we do.
If you have any concerns about the treatment either you and your baby received and would like help or advice, please contact Kiran Jalota on 01926 356030 or email kiran.jalota@alsterskelley.com.
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