After four years, the much-awaited government-commissioned independent review of maternity services at Nottingham University Hospitals NHS Trust has been completed and published here. Led by Donna Ockenden, the review was prompted by significant concerns about the quality and safety of maternity services at the Trust. The final report makes for damning reading, finding that a number of women and newborns suffered potentially avoidable harm or death. It also highlights toxic working conditions, allegations of cover ups, failures to escalate incidents and learn from mistakes. Ms Ockenden, a nurse, midwife and community activist, clearly states that: ‘The culture of compounding of harm needs to stop!’
The report draws on more than 2,500 family cases, over 2,000 sets of medical records, and accounts gathered from families and staff.
It is frustrating that, as Ms Ockenden says herself – ‘Many of the themes identified throughout the report are not new to those who oversee maternity care in England.’
Understaffing, toxic culture, bullying and racism
The report found considerable issues with understaffing on maternity wards, but beyond that paints a horrifying picture of ‘toxic cultures and poor behaviours’ by senior staff. Midwives described behaviours that were unprofessional and ‘cruel’ to women, with attempts to escalate concerns going unheeded. Staff also described bullying and reported that raising concerns ‘sometimes led to criticism, minimisation, or even threat.’ The report concludes that there appeared to be an ‘enduring culture of bullying, racism, poor people management and low staff morale across the whole Trust’. How can safe care possibly be consistently provided in these circumstances?
Failures were also noted in recognising and responding to vulnerable patients, including those with language barriers. The report references staff being encouraged by those leading the labour ward to delay admission or keep mothers at home, and staff reported being fearful of pulling the emergency buzzer. These findings particularly resonated with me having acted for children whose births were unnecessarily delayed with terrible consequences.
Further troubling findings were that challenges identified in the review were known ‘by service and corporate leaders as far back as 2015’ but that ‘a number of known issues, challenges and failings in maternity were at various times sidelined and ignored, deemed too difficult or were of insufficient priority.’
It is highly noteworthy that while more than 830 current and former staff engaged with the review, a number of senior colleagues did not, which has led to a call for a statutory public inquiry into maternity failings – one that could compel evidence.
Brain injury and cerebral palsy
The review identified multiple examples where failures in neonatal care may have contributed to long-term brain injury and adverse neurodevelopmental outcomes. Cases were noted where ‘babies experienced severe hypoglycaemia with prolonged low blood glucose levels, seizures, or hypoxic brain injury,’ with some of these injuries found to be avoidable. Injuries of this nature are utterly devastating, with potentially vast lifelong consequences.
From my own experience of medical negligence cases, learning from when things go wrong is the key to improving future care. The report details that families were not consistently included in learning processes, with some reporting that their accounts were altered or that things were ‘covered up.’ This failure to listen to patients, be upfront, and learn from problems is a theme found across multiple reports into maternity care.
Unfortunately, given my experiences in working for children affected by birth injuries and their families, while I am deeply saddened, I am not shocked by this report. My team at Kingsley Napley has been writing about these issues for many years — see our blogs on birth injuries and maternity services here: Birth | Kingsley Napley.
Moving forward
Nationwide concerns around maternity services are being considered by Baroness Amos, appointed last August as chair of the National Maternity and Neonatal Investigation. Her final report is expected imminent and the recommendations she will make are keenly anticipated.
The Ockenden report sets out immediate and essential actions applicable to Nottingham but also to maternity services across England. Key to these is that women must be at the centre of clinical communication and informed decision-making, and must be able to seek additional clinical review through Martha’s Rule. My colleague Kirsty Allen having recently written an article querying when Martha’s Rule would include maternity services, I am relieved that in response to the report it has been announced that there will be an extension of the Rule to all maternity settings.
Other recommendations that struck me as particularly important include: a mandatory field in triage documentation to capture the woman’s own account and concerns; meaningful communication with parents — including use of translation where required — as routine practice; robust processes for information-sharing between organisations to enable accurate risk assessment; and clear maternity-specific Duty of Candour guidance.
I share the report’s conclusion in its great sadness for those involved, and in the hope that ‘through listening to the experiences of women, families and front-line staff,’ trust in maternity and neonatal services can begin to be rebuilt.
My final reflection is that Donna Ockenden makes reference to the statistics around the cost of clinical negligence claims, which have received considerable recent press attention. However, she noted that behind the figures are ‘the incalculable effects — financial, physical, emotional and psychological — on the families themselves,’ and I would suggest that the findings of her report serve to further underpin this.
Further information about the work of the Kingsley Napley team can be found here:
Read about birth injury cases we have acted in – Case Studies | Kingsley Napley
