The findings of the Ockenden Review have detailed a number of “shocking” examples of maternity care failings by Shrewsbury and Telford Hospital NHS Trust.
Here are some of the most high-profile findings from the review.
– Compassion and kindness
One patient said staff were “dismissive” and the obstetrician “flippant” and “abrupt” after they described the woman as “lazy”.
Another woman was left “screaming for hours” before problems that required intervention were identified. The attitude of the midwives reportedly made the situation worse.
– Place of birth: Assessment of risk
One woman who delivered in a stand-alone birth centre suffered a catastrophic haemorrhage requiring transfer to the consultant unit, where she died. The family said they were not informed of the risks of birth in a midwifery unit.
Another patient who laboured at the birth centre was not adequately monitored as “the unit was busy”. There was a delay in transferring the mother to the labour ward and the baby was delivered in a poor condition having suffered a brain injury.
– Clinical care and competency: Management of the complex
There was a delay in treating a woman’s severe high blood pressure and, following delivery, there was a further delay in seeking senior clinical advice. She died later in another hospital.
The first report outlines local actions for learning and immediate and essential actions to improve safety in maternity services for the SaTH and across England#ockendenmaternityreviewhttps://t.co/AXpJKp947P
— Donna Ockenden (@DOckendenLtd) December 10, 2020
– Escalation of concerns
One woman who was admitted with contractions and early signs of infection late in her second trimester of pregnancy was seen by a junior doctor and discharged without higher level assessment. Several hours later she was readmitted and her baby was born premature.
– Management of labour: Monitoring of fetal wellbeing, use of oxytocin
Some mothers were regularly given the drug oxytocin which increases contractions.
One woman was in labour and there were fetal heart rate concerns. Despite the abnormal cardiotocograph (CTG), oxytocin use was continued throughout the labour. At the caesarean section, there was evidence that there had been an obstructed labour. The baby suffered from hypoxic brain injury and died some months after birth.
Another patient who was admitted in normal labour had CTG abnormalities in the second stage which were not recognised, it was also not recognised that the maternal heart rate was being recorded rather than the fetal heart rate. The baby was born in poor condition, developed hypoxic brain injury and died several months later.
We commit to implementing all of the actions in this report https://t.co/mMrZkq2Azk
— SaTH (@sathNHS) December 10, 2020
For other mothers, the medication was used where babies had already demonstrated a dangerous heart rate and long delays meant some babies were left with brain injuries such as cerebral palsy.
– Traumatic birth
One patient had repeated attempts at forceps delivery. The baby sustained multiple skull fractures and subsequently died.
Another woman had repeated attempts to deliver the baby using forceps. The infant was found to have skull fractures after birth and subsequently developed cerebral palsy. There was no investigation.
– Bereavement care
A woman whose baby died after a particularly traumatic delivery was seen by the consultant afterwards. The consultant was described as having “no compassion or understanding of the trauma experienced”.
A mother whose baby died 17 hours after birth said she and her partner were offered “no support” and hospital staff were “lacking in compassion and actually making it so many times worse”.