The review calls for immediate action to improve care and safety in maternity services across England, focusing on areas, such as safe staffing, escalation and accountability, clinical governance and robust support for families.
The review into almost 1,600 clinical incidents identifies failures to listen to families, failure to learn from clinical incidents and failure of multiple external bodies to act in improving maternity services at the Trust over two decades.
It also found that where investigations did take place, they did not meet the expected standards at that time and failed to identify areas for improvement in care.
Milton Keynes Hospital have responded to the Ockenden review of maternity services:
At Milton Keynes University Hospital, we recognise that the release of the Ockenden report has raised many issues around maternity care, not only in Shrewsbury and Telford, but across the country. We understand that those who are currently or soon to be accessing maternity services might have questions about the safety of the care they will receive.
MKUH maternity services are committed to providing those who use our services with a safe and a positive experience, where their choices for pregnancy, birth and postnatal care are respected and supported, and we aim to ensure all the options are available to them (where medically appropriate).
We do this by working in partnership with the MK Maternity Voices Partnership (a group of past and present maternity service users that is independent to the hospital) to collaborate on the development of our services and ensure that we hear the voices of those who have experienced our care so that we keep improving and developing our services.
Since the Ockenden report has been released, we have reviewed the immediate and essential actions to identify if there is anything we need to implement promptly to support safe care. We have also undertaken another review of our continuity of carer teams to ensure we have the midwifery staff in place to continue to support this model of care.
As well as this, we have made the following developments within the maternity service in recent months:
- appointed two consultant midwives who offer specific clinics to enable the development of individualised birth plans
- hold live weekly digital forums to provide information and answer any questions about maternity care;
- extended our birth planning antenatal appointment to an hour and developed an information pack and birth preferences sheet to support informed choices about birth;
- worked with our ambulance service to provide those choosing a home birth with more information about transfer times should they need or choose to come into the hospital at any point during their labour or birth.
It is important to us that anyone using our services discuss any concerns they may have with our team. If you are not sure how to contact us, are worried, or you are not sure who the best person is to speak to, please see below the options available to speak to one of the team.
You can also phone your named midwife directly on the mobile number which she has provided. If you have an urgent question or concern, or you think you may need to come into the maternity unit please phone the Labour Ward directly.
If you want to discuss your experience with an independent person, please contact the MK Maternity Voices Partnership at - firstname.lastname@example.org
What is the Ockenden review?
The Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, led by Donna Ockenden, was commissioned by NHS Improvement on behalf of the then Secretary of State for Health and Social Care Jeremy Hunt in 2017. It was prompted after the parents of Kate Stanton Davies and Pippa Griffiths asked for further answers following their daughter’s deaths in 2009 and 2016. A further 21 other maternity cases of concern at the Trust were highlighted.
During the last five years the scope of the review was extended to include 1,862 family cases, the majority of which received treatment at the Trust between 2000 and 2019.
However after removing duplication of recording, and excluding cases where there were missing hospital records or consent for participation in the review could not be obtained, the number of families included in this review is 1,486. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
The review team used medical records, documentation from the Trust and interviews and surveys with families to conduct each clinical incident review. The team also conducted an engagement exercise with staff past and present to ascertain an understanding of the culture of the organisation.
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