Ockenden Maternity Review: A view from the front line in Shropshire

The Ockenden Report, to be published this morning, was commissioned by Jeremy Hunt in 2017 after the parents of babies who died in the care of Shrewsbury and Telford NHS Hospital Trust (SATH) were distraught about the uncaring response of staff to their bereavement. Concerns were also raised about the numbers of preventable baby deaths.

The report of the Ockenden maternity review, which investigated 1,862 cases, will add to several recent reports detailing catastrophic failures within other NHS Trusts. This article sets out the wider context for the failures at SaTH and makes recommendations for improvements to the way that care and safeguarding is managed across the NHS.

Over the last few years, there have been frequent reports of catastrophic failures within NHS Trusts, the most recent including the East Kent Hospitals University Trust, Liverpool University Hospitals NHS Trust, the University Hospitals Birmingham Foundation Trust and the response and hand-over times in the West Midlands Ambulance Service.

Many of these scandals have their roots in five actions of former governments:

  • The NHS and Community Care Act 1990 separated purchasers and providers of NHS & social care, setting up competition between providers and creating an NHS internal market for health care.
  • The Health and Social Care Act 2003 Act established of foundation trusts intensifying competition.
  • In 2014, a national tariff payment system was introduced resulting in prioritisation of some activities.
  • The American concept of ‘managerialism’ was adopted by the Department for Health and NHS management. The concept of profit within healthcare flourished. Senior NHS trust managers who had little or no experience of front-line NHS activities were appointed. Some excellent clinical staff were promoted to managerial posts without the training or support to perform their new roles.
  • The decade of austerity, starting in 2009/10, resulted in stagnation of NHS funding. Clinical and other services were forced to take annual budget cuts of 3% to fund favoured developments. Some services lost up to 25% of their budget. NHS activity increased significantly with inpatient admissions increasing by almost 30%. The costs of some surgical treatments, particularly ‘key-hole’ endoscopic procedures, rose considerably.
  • Novel investigations and treatments increased the drain on resources.

The result was promotion and generous funding of some services, especially surgical procedures, while at the opposite end of the spectrum principally non-surgical services such as maternity, emergency, mental health and care of the elderly, withered with staffing and useable equipment frequently dropped to unsafe levels.

Several trusts or services within trusts developed a highly corrosive culture of bullying, undermining and blame, coercing staff into working beyond safe levels and blaming individuals for resource deficiencies. A recent search for “bullying” in the Heath Service Journal produced 1,194 results.

A constant barrage of scandals in many trusts led to several public inquiries including those at the Mid-Staffordshire NHS Foundation Trust (Francis Report), Morecambe Bay NHS Foundation Trust (Kirkup Report), the Christie Inquiry and the Shrewsbury and Telford NHS Hospital Trust (Ockenden Report).

These malignant regimes were allowed to grow and spread to other services and trusts. Failing NHS executives moved to different positions but without any mechanism to control the spread of the dysfunctional culture.

The Care Quality Commission has demonstrably failed to achieve its objective of maintaining acceptable levels of patient care, governance, staff well-being and financial competence.

Modern matrons were created from the Francis Report to ensure adequate standards of care but they were quickly diverted into ‘bed managers’ in many hospitals, losing trusts a valuable resource for maintaining standards.

In Shropshire, the local Joint Health Overview and Scrutiny Committee appeared to have no clear understanding of the issues in SATH.

In SaTH, a bullying, undermining and blame culture developed. This led to increased staff disciplinary investigations and dismissals, early retirements and resignations, which has only recently begun to ease.

I and others reported the bullying culture and safety issues to senior SaTH managers and the regulators, including the Care Quality Commission, NHS Improvement and The National Guardian between 2016 and 2018, including over 50 specific incidents involving over 100 members of staff. Maternity staff were included in those who were bullied. However, this did not eradicate the problem with bullying still reported by 20% of staff as recently as the 2020 SATH Staff Survey.

There are five reforms that would resolve or improve the current health care crisis in England:

  1. The government should implement one of the most important recommendations of the Francis Report of the inquiry into the Mid-Staffordshire NHS Trust in 2013 – the establishment of a statutory regulatory body for all NHS managers, with specified training, accreditation and a code of conduct.
  2. The NHS should prioritise safety over activity, as happens in the aviation industry.
  3. There needs to be adequate NHS and social care funding – UK current spend is the second lowest in G7 Group.
  4. An NHS National Wellbeing Guardian should be established to lead the army of local Wellbeing Guardians. The traditional safety nets within NHS Trusts should be re-established, including senior medical and allied professions committees, with representation at trust board level.
  5. Integrated Care Systems and health overview and scrutiny committees should comprise professionals with clear understanding and experience of health and social care provision, including public health, and should ensure that NHS Trusts meet their safety as well as activity targets.

* Bernie Bentick is a retired consultant in gynaecology & obstetrics at Shrewsbury and Telford NHS Hospital Trust and a Lib Dem councillor on Shrewsbury Town Council & Shropshire Council.

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  • nigel hunter 30th Mar '22 - 10:27am

    Yes ,the problems of the NHS boil down to passed Government actions THESE GOVNT FAULTS SHOULD BE POINTED OUT TO THE PUBLIC. Your proposals should be looked into. Journo,s love to find stories but whilst finding the faults FAIL to show the good that is done in the NHS. and the vast majority of hospitals that are run successfully.Journo,s actions steer the public,s trust in the organisation into negativity.A slow whittling away of the NHS helps the Govnt weakening the system towards privatisation.
    The NHS an organisation that needs to exist for all. A constant whittling away of the system must stop .Govnt actions have not helped re ,lack funds,reduced pay over the years,lack of staff and now taking away free parking for nurses.Do we really want ‘Americanisation’ of the NHS making health just one more cash cow for some 2nd class care for the many.

  • Almost nineteen years after I gave birth to a Group B Strep baby and two days before I go in for gynae surgery I despair at the failure of the NHS to listen to women; and worse, to try to discredit women when they complain.

    It is a disgrace that a single baby in Shropshire died of Group B Strep when it is an easily identified infection that can be treated with anti biotics.

    May the children who have been so senselessly lost rest in peace and may the NHS root out misogyny and bring in screening of pregnant women for Group Streptococcus. Now.

  • Catherine Hodgkinson 31st Mar '22 - 11:49am

    One thing I find hard to understand is why these scandals were not picked up sooner. Surely death rates at hospitals and surgeries etc are analysed and anything above the norm investigated? Just how many cover ups have there been? and how many are still happening?

  • Phil Beesley 31st Mar '22 - 12:33pm

    Catherine Hodgkinson: “Surely death rates at hospitals and surgeries etc are analysed and anything above the norm investigated?”

    Thankfully they are. Basic statistics will show up areas where there are big failures, but they won’t show up general problems which blend into local health differences or are covered by local successes. Humans, whether as staff whistleblowers, patient families or observers of statistical weirdness, are best able to identify problems.

    I’ve never liked the expression “post code lottery”. One of the consequences of local health service management is that care is delivered differently in different places. If we want a health service which provides centres of excellence, some places have to be “less than average”.

  • CATHERINE HODGKINSON 31st Mar '22 - 2:20pm

    In reply to Phil Beesley i would say that the analysis of the statistics is inadequate and more should be done to ensure the figures are interpreted properly.

  • David Chadwick 1st Apr '22 - 1:07pm

    Excellent blog Bernie thank you for sharing.

  • Barry Lofty 1st Apr '22 - 3:57pm

    Just had a phone conversation with one of my daughters on this subject, until recently she had a working knowledge on childbirth issues and listening to her views I think she would find much in Nigel Hunters assessment to agree with.

  • @CATHERINE HODGKINSON – I think what is the real problem here is that thee seems to be no statory body with the power to investigate.

    With IT we have the Information Commissioner, who has the legal authority to investigate data breeches and to whom businesses legally need to report data breeches to. All this without the involvement of a minister.

    I suggest the health sector (ie. NHS and private) is in need of a similar arrangement.

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