Posted on: 4 April 2022

Read a response from our CEO about the Ockenden Report into Maternity Services at Shrewsbury and Telford NHS Trust

"Like everyone I am quite horrified and sad about what the Ockenden Report into Maternity Services at Shrewsbury and Telford NHS Trust has uncovered.

The review was initially of 23 families’ cases, but it grew to 1,486 between 2000 and 2019. Failures in care may have led to the deaths of more than 200 babies, nine mothers and left other infants with life-changing injuries.

It is a tough read but a necessary one – not just for anyone involved in wider maternity services (as many of our staff are – from our mother and baby unit, Coombewood, through to our Health Visitors and District Nurses) but more widely for everyone’s practice too.

This includes our Board and Executive Directors, and every team or professional, about what can happen when patients and their families are not listened to, or staff who see something they are concerned about, but don’t speak up, with a culture that allows such things to persist as they did at that Trust.

Everyone in the whole NHS and social care must think about these issues for our day to day practice and truly listen to what patients and staff are telling us.

We will be writing our own summary and reflections on the report, though some of the immediate lessons that have been drawn out by Catherine Knights, our Director of Quality – see below, “Learning for CNWL.”

Our own Safety Strategy says:

“Our strategy provides a “call to action” for all staff to reflect on what is important in their particular service to improve safety for our patients, and safety for our staff. No matter what your role is in the Trust, whether you work in our corporate teams or our direct clinical services, you have a role to play in supporting us to improve safety across CNWL.”

It is also linked to creating a sense of safety for people to speak up, without fear of recrimination. That’s why we are working on SCARF – a culture of being Safe, Compassionate, Reflective and Fair.

SCARF was introduced, “because staff have told us that change was needed to develop a climate of openness and psychological safety. SCARF started from a shared belief that people set out to do their best but sometimes things go wrong and mistakes are made. However; we want to go further than looking at systems and process for managing incidents and concerns. We want to adopt a new mindset and create a culture where we are fair to our people and those that use our services, where we all feel enabled, supported and empowered to see situations as opportunities to learn.”

Learning for CNWL

Whilst clearly there is maternity-specific learning, there are wider themes of learning and we wish all teams to reflect on and consider the importance of :

  • Following national clinical guidelines
  • Escalating concerns about a patient/service user with the MDT/ senior clinicians
  • Working collaboratively across disciplines and cohesively in each multi-disciplinary team
  • Listening to concerns from patients/service users and their families about the quality of care and taking these seriously
  • Addressing themes identified in serious incident and complaint investigations so they do not recur
  • Intervening early in an episode of illness
  • Displaying compassion to patients/service users and their families
  • Ensuring response letters to complaints contain accurate information and address their concerns
  • Ensuring services have safe staffing levels and escalating if not
  • Supporting staff to be trained in the skills and knowledge needed to safely run the service
  • Ensuring teams use their Consultants’ clinical expertise
  • Supporting locum doctors to be a full member of the MDT and with their work
  • Supporting any changes in the leadership team to fully understand the strengths and challenges in the services they oversee, detailing plans for improvement

And this is a conversation so let’s hear from you and hear how you are sharing your good work and guarding against poor standards of care.

We are living through exceptional times, where demands are being made of us we couldn’t have imagined a few years back. We are still facing mounting pressures and a great number of people look to you now for your help – knowing that you are skilled and compassionate, but also that you are part of a team and a Trust they can rely on.

Our very human reaction to the sadness of the families at the heart of this report, must be used as a check on ourselves and every service.

Thank you for all you are doing."