Skip to main content

Ockenden Review

Volume 808: debated on Monday 14 December 2020


The following Statement was made in the House of Commons on Thursday 10 December.

“With permission, Madam Deputy Speaker, I would like to make a statement on the initial report from the Ockenden review, which was published this morning.

Before I update the House on the findings, I wish to remind the House of the tragic circumstances in which the review was established. It was requested by the Government following concerns raised in December 2016 by two bereaved families whose babies had sadly died shortly following their birth at the Shrewsbury and Telford Hospital NHS Trust. I am grateful to my right honourable friend the Member for South West Surrey Jeremy Hunt, who, as Secretary of State for Health and Social Care, asked NHS Improvement to commission the independent inquiry.

The inquiry is chaired by senior registered midwife Donna Ockenden, a clinical expert in maternity who was tasked with assessing the quality of previous investigations and how the trust had implemented recommendations relating to newborn, infant and maternal harm. As the report acknowledges, this year the country has rightly united in pride and admiration for our NHS, but we must accept that in the past not everyone has experienced the kindness and compassion from the NHS that they deserved.

The review team has met face to face with families who have suffered as a result of the loss of brothers and sisters, or who have, from a young age, been carers to profoundly disabled siblings. The team has also met parents in cases where there have been breakdowns in relationships as a result of the strain of caring for a severely disabled child or the grief after the death of a baby or resultant complications following childbirth.

The original terms of reference for the review covered the handling of 23 cases; however, since its launch more families have come forward and extra cases have been identified by the trust. As a result, the review now covers 1,862 cases, and this has led to an extension of its scope and delivery. An interim report has therefore been published today, and it contains a number of important themes that the review team believe must be shared across all maternity services as a matter of urgency. Indeed, I personally, and the Government, pushed to have this interim report at this point in time so that we could learn from the findings of the inquiry so far.

This is the first of two reports, based on a review of 250 cases between 2000 and 2018; the second, final report will follow next year. Today’s report makes it clear that there were serious failings in maternity services at the Shrewsbury and Telford Hospital NHS Trust. I would like to express my profound sympathies for what the families have gone through. There can be no greater pain for a parent than to lose a child. I am acutely aware that nothing I can say today will lessen the horrendous suffering that these families have been through and continue to suffer. Nevertheless, I would like to give my thanks to all the families who agreed to come forward and assist the inquiry.

The review team held conversations with more than 800 families who have raised serious concerns about the care they received. I know that it has not been easy for them to revisit painful and distressing experiences, but through sharing their stories we can ensure that no family has to suffer the same pain in the future. From the outset the inquiry wanted families to be central to the team’s work and for their voices to be heard, and I am pleased that the families were able to see the report first, this morning, shortly before it was presented to Parliament. I assure them, and Members of this House, that we are taking today’s report very seriously and that we expect the trust to act on the recommendations immediately.

I thank Donna Ockenden and her team for their diligent work. Their valuable work provides essential and immediate actions to improve patient safety and ensure that maternity services at the trust are safe. Four of those actions are for the trust and seven are for the wider maternity system. The report sets out clear recommendations for what the trust can do to improve safety relating to overall maternity care, maternal deaths, obstetric anaesthesia and neonatal services.

The report also sets out actions that can make a difference to the safe provision of maternity services everywhere. They include recommendations on enhancing patient safety and how we can best listen to women and families, developing more effective staff training and ways of working, managing complex pregnancies and risk assessments throughout pregnancies, monitoring foetal well-being, and ensuring that patients have enough information to give informed consent. I welcome those recommendations and the others in the report. We will be working closely with NHS England, NHS Improvement and Shrewsbury and Telford Hospital NHS Trust, which have accepted each of the recommendations and will take them forward. We learn from these tragic cases so that we can give patients the safe and high-quality care that they deserve.

Patient safety is a big priority for me and the Government. We want the NHS to be the safest place in the world to give birth, and this report makes an important contribution towards that goal. Our ambition is to halve the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries in babies occurring during or soon after birth by 2025. We have achieved early our ambition of a 20% decrease in stillbirths by 2020, but of course there is always more to do and we owe it to the families to get it right.

The Ockenden review is an important document that vividly shows the importance of patient safety. I assure the House that we will learn the lessons that must be learned so that the tragic stories found within these pages will never be repeated again. I commend this Statement to the House.”

My Lords, I first declare an interest as a non-executive director for a London hospital trust. I thank the Minister for the debate today. This is a harrowing report, and the latest in a series of reports over recent years. It follows on the heels of the Morecambe Bay report, and we know that the East Kent report was launched earlier this year to investigate 54 babies dying between 2014 and 2019.

I first congratulate Donna Ockenden on this interim report. As she rightly says in her letter to the Secretary of State,

“we want to bring to your attention actions which we believe need to be urgently implemented to improve the safety of maternity services at The Shrewsbury and Telford Hospital NHS Trust as well as learning that we recommend be shared and acted upon by maternity services across England.”

The scale of the findings in this interim report is distressing in the extreme. The relentless campaign of parents Rhiannon Davies and Richard Stanton, and Kayleigh and Colin Griffiths, must be recognised, and we must pay tribute to and thank them. At a time of greatest grief—the loss of a baby—they have done something vital to ensure that other parents do not suffer the losses they have.

Babies suffered fatal skull fractures from forceps use; women were left screaming in agony for hours; infants developed long-term disabilities as a result of terrible maternity care. There were baby deaths, high maternal deaths, and a catalogue of incompetence, neglect and cruelty. There was failure to handle high-risk cases correctly, an overzealous pursuit of natural, vaginal births leading to a reluctance to perform caesarean sections, and inadequate consultant supervision. Struggling mothers were mocked and called lazy. Mothers were blamed for their baby’s death. Parents were not listened to; legitimate questions were not responded to and blocked; responsibility was not taken.

There was poor assessment of risk and no discussion of risks with mothers. Practice in assessing ongoing risk was poor. Escalating problems were spotted too late, leading to delay in transfer to hospital and death. There was poor ability to spot the refusal to acknowledge. Escalation was seen by midwives as a slight on their ability, not a prudent response to risk. As bad was the internal culture which allowed this to carry on without proper, effective management or regulatory oversight. There were adversarial attitudes between doctors and midwives. Perhaps the Royal Colleges need to talk to each other about the lack of mutual respect for their particular expertise and experience, and the value placed on these.

This is an interim report because Ockenden is rightly concerned that change needs to start immediately. One hopes that it has already been happening in the trust, rather than waiting for the full report and for the Government to take time to consider it. That might literally cost lives. It might mean more babies suffering damage, which means disability for the whole of their lives. This concerns not only deaths but sometimes severe disabilities, which cause huge suffering for the child and have a huge impact on and cost for their families and, indeed, for the state.

It is now clear that the Ockenden review will be far larger and take far longer than was originally intended. Can the Minister assure the House that the review has the resources necessary to complete the final report as soon as possible? There are seven immediate and essential actions outlined in this interim report. What progress is being made to implement these recommendations? What actions is NHS England taking to implement these interim recommendations across England? The turnover of leadership at board and officer level in this trust was surely a warning sign that something was amiss. Why was there not earlier support and intervention by NHS England? I know how appointments are made at senior level; they have to be signed off by NHS England. It must have known. What happened? One needs to ask the same questions of the CQC, both in terms of leadership instability at the trust and why the glaringly obvious warning signs of infant and maternal death were not acted upon sooner.

More broadly, can the Minister explain what action is being taken to ensure that there are enough staff in all maternity units? Perhaps the Government can, this time, commit to legislating for safer staffing levels. What is being done to tackle the current estimated 3,000 midwife vacancies?

Finally, for the vast majority of us who give birth in NHS hospitals, it is a wonderful experience, and a very safe one. We want that to be available to all women.

I declare an interest, as my husband is a medical director for NHS England, but not in the region where this hospital is located.

From these Benches, I want to start by sending our heartfelt love and admiration—as, I am sure, do many across the House—to those parents and families who will have an empty place in their home this Christmas, due to the poor care they received at Shrewsbury and Telford Hospital NHS Trust maternity services. This report is distressing and shocking to read. It is hard to comprehend that it describes a care system in this country, in this century. It describes everything from the lack of basic things like human empathy, compassion and support, to poor medical practice and lack of carrying out best practice and adhering to agreed professional standards. This has led to grief, long-term disability, lifelong complications and the unnecessary deaths of newborn children and mothers.

This is not the first case of poor practice in maternity care that has come to light after brave families and parents have refused to be cowed and silenced. Morecombe Bay should have been a wake-up call for ensuring that systematic, integrated changes took place. It is clear that cultural and systematic change at scale and in depth has not happened, despite previous warnings. The healthcare regulator this year reported that four out of 10 maternity services do not meet the safety threshold of care. I ask the Minister why, in 2020, that is an acceptable statistic.

In 2017, the £8.1 million national maternity training fund was withdrawn. Does the Minister now, in hindsight, regret this, and will he seek to re-establish this fund urgently? Will the Minister inform the House who is responsible—politically and managerially—within NHS England for ensuring that, this time, the changes highlighted are implemented, particularly in the seven areas seen to be urgent? What is the timetable for implementing the seven immediate and essential actions required across the NHS? What resources will be allocated to implement the 27 local and 7 immediate and essential actions required?

This must not be another report that gets sympathetic words from those with political and managerial responsibility but then ends up on a shelf gathering dust. That is why the Minister needs to outline a timetable for implementation, what resources will be allocated and who, ultimately, is accountable for ensuring that the systematic, deep changes happen, so that no family has to deal with the kind of grief and trauma that so many families in this report have had to deal with.

My Lords, I start by echoing the very thoughtful words of the noble Baroness, Lady Thornton, and the noble Lord, Lord Scriven, in their reflections on this harrowing report. It does make desperately awful reading. Any noble Lord who took the time to read the report would surely be enormously moved, not just by the story of the cultural and practical problems at the Shrewsbury and Telford Hospital NHS Trust, but also by the personal testimony of Rhiannon Davies—who fought an 11-year campaign after the death of her daughter, Kate—and of Kayleigh Griffiths. They both campaigned stubbornly and with great determination after the deaths of their daughters. They have done a phenomenal thing in bringing this situation to light, and we owe them our compassion and our thanks for their hard work and determination.

We also owe great thanks to Donna Ockenden, who has done a memorable job in terms of this report. It is a massive enterprise that is the result of a huge human investment of time and emotional commitment by Donna and her staff. The report itself is not only huge in scale but great in the humanity with which it deals with this difficult subject. We give great thanks for that.

I reassure both the noble Lord, Lord Scriven, and the noble Baroness, Lady Thornton, that we absolutely take this report seriously. It does outline major issues in the culture of many maternity wards. That is a cultural challenge that is both recognised by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, and something that they are working on very well indeed. But I accept that more can be done. In its application, the Government commit not only to implementing the recommendations at trust level but to ensuring that the message made very clearly in the Ockenden report is heard throughout the NHS system.

We are committed to a major investment in the education around midwifery, which includes the rewriting of curriculums, and the Better Births programme, which has already delivered enormous value. There will be a maternity programme review that will update the Better Births programme. There has also been a £9.4 million investment in maternity safety pilots, some of which will be focused on training and some of which will be on safety measures—exactly the kinds of measures that are alluded to in the report.

But the most challenging and, I think, moving element of the report is the stories of the parents themselves and how they were not listened to. This echoes the findings of the report by the noble Baroness, Lady Cumberlege, which, I think, has moved everyone in the House. Time and again we hear the same story, of how those who have witnessed wrong practices and poor culture in the NHS have had to fight the establishment so hard in order to have their voices heard. If any noble Lords heard Rhiannon Davies speak about her own experiences campaigning on this, who would not be moved by that?

We take on board very seriously the recommendations of the noble Baroness, Lady Cumberlege, for a patient safety commissioner. We acknowledge her amendment to the Medicines and Medical Devices Bill, and we look forward to the Report stage of that Bill in the new year.

I would also like to remind noble Lords that all maternity major incidents—certainly neonatal deaths, stillbirths and brain injuries—are now routinely referred to the Healthcare Safety Investigation Branch, which does an independent investigation. This is an important development since many of the incidents reported by the Shrewsbury and Telford Hospital NHS Trust report. HSIB is doing extremely important work, and I believe that this will be a very large improvement.

Both the noble Lord, Lord Scriven, and the noble Baroness, Lady Thornton, raised leadership. I reassure them both that we have put in place much stronger surveillance, both by the regulators—the CQC and others—and by NHS England to keep track of these sorts of incidents, so that we can much more quickly identify weak spots in the area.

On the question of staffing levels brought up by both noble Lords, I reassure them that the recruitment of midwives—3,000 were committed to in 2018—is going apace. We have committed to a major investment in marketing in order to ensure that we hit our targets on that.

The noble Lord, Lord Scriven, asked whether we were committed to change, or whether this report will sit on the shelf and gather dust. I reassure the noble Lord, and all noble Lords, that we are still very much committed to the maternity ambition to halve stillbirths, deaths and injuries between 2010 and 2025. We are already nearly half way there on that ambition, and we will work relentlessly to ensure that it is achieved.

I declare an interest, because I was privileged to work for over 35 years in a maternity unit, with brilliant midwives and doctors—I was a lead obstetrician—to which the events described in this report were totally alien. So we have another report on the failings of maternity services. The root cause of this, as found in previous reports, is the unquestioning practice of regarding all pregnancies as low risk and striving for a natural birth. Does the Minister agree that, for better outcomes for the mother and her unborn baby, society should expect a better working relationship between midwives and obstetricians, while recognising their individual professionalism? This report should be the starting point to making that happen. The Minister mentioned that both Royal Colleges were working together to bring this about. They might be the solution but, if they are not, they will be the ones who are blamed next.

My Lords, I pay tribute to the insight of the noble Lord, Lord Patel, who brings with him not only expertise as an obstetrician, but deep involvement in the patient safety agenda. I completely agree that collaboration and close working relationships between midwives and obstetricians absolutely benefit the collective care of mothers and babies. When that does not happen, and when agendas other than patient safety come into play—around natural births or what type of person should be present at a birth—it is absolutely to the detriment of the safety of both mother and child. I am absolutely determined that the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists step up to their leadership role in resolving this cultural stand-off. As the noble Lord rightly put it, in almost every maternity centre in the country a fantastic service is provided by clinicians and nurses—but, when that chemistry goes wrong, patients suffer, and we cannot let that happen.

My Lords, I declare an interest, as set out in the register, as the chair of the trustees of the Royal College of Obstetricians and Gynaecologists. As the Minister has admitted, this report makes shocking reading, so what steps will the Government take to monitor the improvements they are pledging for maternity services right across the country to avoid the tragedies that are revealed by this review? Will the Government commit to publishing the findings of any future evaluation and, in particular, data on the avoidable deaths and long-term disabilities that result from failures in the care of women during childbirth?

My Lords, policy officials at the DHSC are working with both the CQC and NHS England on improving our surveillance and the publication of data, as the noble Baroness rightly points out. A key development in this area is the work by HSIB to investigate each and every death and major incident in maternity suites. That provides an absolutely invaluable resource to understand where and when things go wrong. We will continue to publish those reports as they happen and will learn lessons from their insights.

My Lords, much of this debate has already focused on the issue of staffing shortages in our NHS, particularly among midwives. I am sure that the Minister is aware of the survey last month from the Royal College of Midwives, which showed that 83% of midwives did not believe that their trust or board had enough staff to provide a safe service and 42% said that half or more of their shifts were understaffed. The Minister referred to recruitment campaigns and investment in future training, but the Ockenden review calls for an immediate focus on relationship building, training and things that will take a great deal of time and resources to deliver, where there are problems. I cannot see any alternative if we are to fill some of those gaps immediately. Training will take many years, but an overseas recruitment of midwives will bring in the staff we need to create the space to allow people to have that training—that time and reflection.

My Lords, I respectfully disagree with the noble Baroness’s insight—the Ockenden review does not point the finger at staffing levels in relation to the problems; it points the finger at a number of items, particularly the cultural problems that emerge when differences of opinion between clinicians and midwives arise and where a culture of respect breaks down. Those cultural differences can be improved by what we would politely call education; it is essential that we invest in the right kind of education in order to bring midwives, obstetricians and gynaecologists closer together and to break down the hierarchical differences and the ideological differences about the best way to have a baby.

My Lords, as a Secretary of State responsible for the health service for some of this period—two years out of two decades—I share in the responsibility for what happened here and for the fact that it was not known about and that action was not taken sooner. I am sure that others who have been Ministers in the department over these two decades will feel likewise.

What is shocking is not only the individual trauma that parents have suffered but the scale of what the Ockenden review discloses—we are grateful to Donna Ockenden and her colleagues for persisting in trying to understand and disclose the scale of what has happened. I ask my noble friend about our responsibility, which was, of course, that there should be external oversight and action taken when these things go wrong. From my point of view, one of my objectives was that there should be more clinically led commissioning so that local clinicians would understand what was happening and have the power to step in.

The Ockenden report shows that, in May 2013, the clinical commissioning groups set up a review that, in October 2013, reported:

“The overall findings of the review demonstrate that this is a safe and a good quality service”.

I encourage Donna Ockenden and the department to look very carefully at how they could ensure that local clinicians responsible for commissioning take that responsibility seriously and act upon it.

On behalf of the Chamber, I thank my noble friend for his touching testimony. He is entirely right; there are two CCGs in the local area: the Telford and Wrekin CCG and the Shropshire CCG. They did exactly what they should have done in 2013, launching an investigation into the levels of service at the Shrewsbury and Telford Hospital NHS Trust. It is not clear why the findings of that report turned out as they did; nor is it clear why other interventions, or potential interventions, by the CQC and other regulators did not get to the bottom of the problem. Those questions will be addressed in the second of Donna Ockenden’s reports, in 2021; there has not been time for them all to be addressed in the interim report, but there is much more to go into, and this is undoubtedly one of the important points she will need to address.

My Lords, I declare an interest as a member of the GMC board. Nothing can excuse the repeated failures and the lack of compassion and kindness exposed by the review. What is so striking is the paragraph in the report that refers to the eight chief executives working in the trust over a period of 10 years and 10 chairs over 20 years —no wonder there is a leadership and governance issue in the trust. I ask the Minister: what on earth have NHS England, NHS Improvement and the CQC been doing? It seems that their interventions, which I suspect have been punitive in nature, have not provided the kind of support that is needed.

Does the Minister agree that we need a wholly new approach to this trust, which gives it high-level attention and provides stability in leadership—not a constant turnover because of an intervention by one or other of the many regulators that can do this—and above all, support from neighbouring services that can provide help? I suspect that this trust needs an awful lot of help to get out of this terrible situation.

My Lords, I completely take on board the noble Lord’s observations. It is true that Donna Ockenden’s report alludes to the failure by senior leadership to monitor and intervene where clearly there were problems. However, let us not confuse correlation with causation. This was not caused by a failure of senior leadership, but by a breakdown in the basic management systems and culture of the maternity services within the trust. That should have been addressed by the senior leadership, but it was not necessarily caused by them. I completely endorse the observation of the noble Lord that neighbouring trusts have an important role to play in checking in and benchmarking behaviours. That is a point made very clearly in the Ockenden report, and one that I hope they will step up to.

I salute the courage of the parents of Kate Stanton Davies, Pippa Griffiths and so many others in their tenacious personal search for truth and justice. Donna Ockenden’s report was harrowing reading. The pain, trauma and inhuman disregard for the safety of baby and mother was palpable, profoundly damaging confidence and trust in maternity services. It made me relive my own decade-long failed attempt to seek information on whether my lengthy abandonment on a bed overnight after 48 hours of labour pain has anything to do with my now 42 year-old son’s brain damage and lifelong disabilities. I was dismissed constantly, admonished for “being an Asian mother too ashamed to have given birth to a disabled child”, which is far from the truth about a much-loved son.

Sadly, I was not alone, as the Ockenden report details. It has been repeatedly confirmed by so many others and by the first maternity advocacy scheme, which was set up in the 1980s to address the high postnatal mortality rate of mothers and babies among Bangladeshi, Pakistani, Somalian, Vietnamese and African women, whose maternity experiences, even today, remain inconsistent and patchy. Therefore, can I ask the Minister what consideration can and will be given to historic grievances in any future review of maternity services, given what the right honourable Jeremy Hunt in the other place, and Donna Ockenden, have said about the experience of mothers and babies highlighted being only the beginning of unearthing potential malpractice across England?

I join others in paying tribute to the personal testimony of the noble Baroness. The story that she tells is extremely moving. One cannot think about the challenges and difficulties that she must have had since that awful night, which she so movingly describes. The report makes it clear that those with a BAME background have disproportionately high rates of difficulty at birth and in maternity services, something which undoubtedly we need to look at more carefully. However, the Ockenden report is not a historic grievances report, and that will not be the focus of our response.

My Lords, this is the second time in six months that this House has been exposed to quite harrowing tales of patients’ experiences in the NHS. I am glad that the Minister mentioned the report by the noble Baroness, Lady Cumberlege, and her call for a patient safety commissioner. Both the Ockenden and the Cumberlege report identified a problem with the culture in the NHS. We cannot go on having review after review. While it is important to listen to the patients’ experiences as part of putting things right, we must learn comprehensive lessons. Will the Minister therefore say just a little more as to how he intends to take the idea of the patient safety commissioner forward, and in particular how that patient safety commissioner will be independent of and not part of the NHS?

My Lords, it would be premature of me to describe in too much detail how any patient commissioner may work, since we are half way through the Bill’s progress. But I would like to reflect on the very good arguments made by my noble friend Lady Cumberlege and her supporters during the Bill’s passage at Second Reading, in Committee and in the amendment-moving process. She has made very convincing arguments for how a patient safety commissioner can be an ultimate destination for those who have not found due process and a sympathetic ear elsewhere in the consideration of their grievances. It is entirely right that any commissioner, whether a victims’ commissioner or any other kind, should feel a strong sense of independence; that is a total benefit that we endorse in the provision of any commissioner. But commissioners are not enough; what we need is a change in culture. That is why Aidan Fowler, the DCMO looking at this, works so hard and why we have a patient safety agenda that works to address this at every level of hospital trusts.