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Found 838 results
  1. News Article
    NHS bosses have written to hospitals telling them to stop using language that implies a bias against caesarean sections when advertising jobs in maternity services. A recent report into an NHS maternity scandal found that a focus on “normal birth” had played a key role in babies dying or being born disabled. Women at the Shrewsbury and Telford trust were forced to undergo traumatic natural births when they should have been offered surgical intervention. However, even since its publication, trusts have published job adverts looking for a member of staff “to help us promote normality” or saying that they are “proud of our commitment to normal birth”. In a letter sent, Dr Matthew Jolly, NHS clinical director for maternity, and Professor Jacqueline Dunkley-Bent, chief midwifery officer, ask maternity services “to review the language that they are using about their services, in job adverts, and any other information designed to support decision-making on pregnancy and birth choices”. The letter continues: “There have been a number of concerns raised about the language used in some NHS trust maternity service job adverts and materials — phrases that suggest bias toward one mode of birth. “The NHS has a duty to provide safe and personalised care to women and families according to best practice guidance informed by evidence and the changes that are taking place in society, midwifery, maternity, and neonatal care services. “It is a fundamental requirement of a maternity multidisciplinary team to inform and listen to every woman, respect their views and help them to try and achieve the type of birth they aspire to.” Read full story (paywalled) Source: The Times, 15 April 2022
  2. Content Article
    In this blog for Refinery 29, journalist L'Oréal Blackett discusses the additional risk and associated worries faced by black pregnant women in the UK. With black women four times more likely to die in childbirth than white women, and 40% more likely to suffer a miscarriage, she examines what action the government is taking to improve outcomes for black women and their babies. She speaks to a number of campaigners who highlight the importance of including black women at every stage of research and policy to tackle race-based health inequalities, and who question whether this is being done by the UK government's new Maternity Disparities Taskforce. She also argues that empowering women to make informed, evidence-based decisions is the most effective way to improve maternal safety for black women.
  3. News Article
    In an ongoing effort to improve care and support for elderly women and women’s health satisfaction and outcomes in general, the government have published their report summarising written responses from 436 organisations and experts from the Women’s Health Strategy call for evidence. The organisations that contributed to the report included participants from the charity sector, academia, professional bodies, clinicians, royal colleges and other general experts in women’s health. The topics highlighted in the report include: Menstrual health and gynaecological conditions, including the impact of premenstrual syndrome on someone’s quality of life. Fertility, pregnancy, pregnancy loss and maternal health, including women not feeling listened to during and after pregnancy and the provision of bereavement support services. Menopause, including suggestions for improvements in training and guidelines for healthcare professionals. Gynaecological and other cancers, including barriers to accessing high-quality, up to date information on risk factors for female cancers. Mental health, including its interaction with other health conditions across women’s life course. Healthy ageing, including the need to increase focus on the health needs of older women and emphasise women may experience the same conditions as men in different ways. Violence against women and girls, including the complications associated with hymenoplasty and barriers to accessing healthcare support for those who’ve been subject to years of violence and abuse. Minister for Women’s Health Maria Caulfield said: “For generations, women have lived in a healthcare system primarily designed by men, for men. We are committed to tackling the gender health gap, and the publication of our strategy later this year will mark a significant step forward.” She added: “I want to thank the expert individuals and organisations who took the time to respond to our call for evidence. The insights you have provided have been stark and sobering but will be pivotal to ensuring our strategy represents the first-hand experiences of the health care system.” Read full story Source: NHE, 13 April 2022
  4. Content Article
    The Department for Health and Social Care (DHSC) launched a call for evidence in March 2021 to inform the first-ever government-led Women’s Health Strategy for England. This report focuses on the survey component of the consultation. Nearly 100,000 people in England got in touch to share: their personal views and experiences as a woman the experiences of a female family member, friend or partner their reflections as a self-identified health or care professional. The results highlight priority areas for action and further research and underpin DHSC’s vision statement for England’s Women’s Health Strategy (published in December 2021). The full strategy will be published in spring 2022.
  5. News Article
    Mums who have given birth at Sheffield's largest maternity unit have revealed all about the "horrible" conditions, with some parents saying they feared for their baby's lives. One mum - a midwife herself - was so concerned about her unborn baby's welfare that she and her partner temporarily moved to London just weeks before her due date. "I felt like my son and I might have died if we had the pregnancy in Sheffield," she said. Several mums have spoken to Yorkshire Live about their stories after a scathing report uncovered the scale of the issues on the Jessop Wing. CQC inspectors highlighted all manner of major issues about the care given at Sheffield Teaching Hospital's specialist maternity unit, including examples of emergency help not arriving when staff called for it. Distraught mums said they were left naked and covered in bodily fluids while others complained about being ignored for hours despite begging for pain relief. Dangerously low staffing levels exposed patients to the risk of serious harm, while midwives themselves revealed a toxic environment of a "bullying and intimidating culture" from senior management. As a Trust spokesperson said "we are very sorry" and vowed to make big improvements, we spoke to some of the families worst affected by the problems as they explained how "basic dignity and care have gone out the window". Read full story Source: 12, April 2022, Yorkshire Live
  6. Content Article
    The newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored. Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby. Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care writes Marian Knight and Susanna Stanford in this BMJ Editorial.
  7. News Article
    The healthcare regulator has been branded “not fit for purpose” after dismissing warnings of the biggest maternity scandal in NHS history, The Telegraph can reveal. Letters seen by this newspaper show that the Care Quality Commission (CQC) told grieving parents it would not support an independent inquiry into baby deaths, just months before such an investigation was ordered. Rhiannon Davies wrote to the watchdog in Dec 2016, alerting the regulator to 19 avoidable deaths of mothers and babies at the Shrewsbury and Telford Hospital NHS Trust, as well as a string of cases where lives were put at risk. However, the head of the CQC at the time assured Ms Davies that the culture was “changing for the positive”, rebuffing her calls for an independent inquiry. Ms Davies had provided the watchdog with details of a string of deaths, which she and fellow bereaved parents had found from publicly available information. The information was contained in a letter to Jeremy Hunt, the health secretary at the time, and shared with the regulator, setting out why families believed an inquiry was required. On Tuesday night, Ms Davies said that the refusal of the CQC to back an investigation, and the false assurances given by its most senior figure, showed how it “never scratched beneath the surface” despite death after death. Ms Davies said that she had “absolutely no faith” in its current ability to regulate and spot future scandals, saying it had “pushed back” every effort made by families to expose the failings at Shrewsbury. “They are not fit for purpose because we cannot trust them to be doing their job properly,” she told The Telegraph. Read full story (paywalled) Source: The Telegraph, 5 April 2022
  8. Content Article
    This analysis by Paul Gallagher, Health Correspondent at i News discusses the prevalence of maternity scandals in the NHS, in light of the publication of the Ockenden Review into failings in maternity services at Shrewsbury and Telford NHS Trust. He highlights the importance of implementing the findings of the review, particularly focusing on the need for a comprehensive plan to tackle workforce shortages. He also highlights the continued existence in some trusts of a culture of covering up harm, evidenced by staff at Shrewsbury being pressured not to talk to investigators, right up until the report's publication.
  9. News Article
    Dozens of families have written to the government expressing concern over a review into failing maternity units in Nottingham. A probe into Nottingham University Hospitals Trust is under way after dozens of babies died or were injured. But families say the review is "moving with the viscosity of treacle". They have called for Donna Ockenden, who led the inquiry into the UK's biggest maternity scandal, to take charge of a review. In a letter to Health Secretary Sajid Javid, a group of 100 people raised concerns with the current thematic review, which has been commissioned by the local clinical commissioning group (CCG) and NHS England, and NHS Improvement. According to the CCG, the review will look at themes and trends and put in "place detailed and measurable actions so improvements can be made fast". But families have questioned the independence of the review and the experience of the team to handle a probe of this magnitude. It is chaired by Cathy Purt, a long-time NHS manager who the families believe has no experience of running complex inquiries or maternity services. The letter states: "If families are to be safeguarded, real intervention is required." Read full story Source: BBC News, 7 April 2022
  10. News Article
    Hospital inspectors have uncovered repeated maternity failings and expressed serious concern about the safety of mothers and babies in Sheffield just days after a damning report warned there had been hundreds of avoidable baby deaths in Shrewsbury. The Care Quality Commission (CQC) found Sheffield teaching hospitals NHS foundation trust, one of the largest NHS trusts in England, had failed to make the required improvements to services when it visited in October and November, despite receiving previous warnings from the watchdog. As well as concerns across the wider trust, a focused inspection on maternity raised significant issues about the way its service is run. When it came to medical staff at the Sheffield trust, the “service did not have enough medical staff with the right qualifications, skills, and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment”, the report said. Inspectors found that staff were not interpreting, classifying or escalating measures of a baby’s heart rate properly, an issue that was raised by Donna Ockenden in her review of the Shrewsbury scandal. Despite fetal monitoring being highlighted as an area needing attention in 2015 and 2021, the most recent inspection “highlighted that the service continued to lack urgency and pace in implementing actions and recommendations to mitigate these risks, therefore exposing patients to risk of harm”. Read full story Source: The Guardian, 5 April 2022
  11. News Article
    Detectives have begun an investigation into the deaths of two babies at the hospital trust at the centre of the largest maternity scandal in NHS history. The babies died in separate incidents last year at the Shrewsbury and Telford Hospital NHS Trust, both during birth. One of them was a twin. The cases were among 600 examined by West Mercia police alongside an inquiry by Donna Ockenden, a senior midwife and manager, into failings at the trust. Her report revealed last week that 201 babies had died and 94 suffered brain damage as a result of avoidable mistakes. Nine mothers also died because of errors in care. Detectives are working with prosecutors to determine whether charges should be brought over the two deaths last year, after years of warnings that maternity services were in crisis. West Mercia police said they were investigating the trust as an organisation as well as individuals. The trust could face a charge of corporate manslaughter if it is found that the way the hospital organised and managed its services caused a death that amounted to a “gross breach” of its duty of care. If found guilty, the trust would face an unlimited fine. Individuals charged with gross negligence manslaughter could go to jail if convicted. The move by the police comes amid growing fears that the unsafe care identified in the report could be taking place in maternity services in other parts of the country. Read full story (paywalled) Source: The Times, 3 April 2022
  12. Content Article
    Sharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this article, Sharon reflects on the significant impact of the harm caused by Primodos, a widely used hormone pregnancy test prescribed to women in the UK between 1958 and 1970. Primodos is now known to cause miscarriage, stillbirth and birth defects, and this article examines the culture of denial and an absence of state and corporate pharmaceutical accountability that allowed patients to continue to be harmed over decades.
  13. Content Article
    In March 2015, Bill Kirkup published his report on avoidable harm in maternity services at the Morecambe Bay NHS Trust. His introduction carried a warning: “It is vital that the lessons, now plain to see, are learnt... by other Trusts, which must not believe that ‘it could not happen here.’” With the publication of the Ockenden report, we now know that one of those other Trusts was the Shrewsbury and Telford NHS Hospital Trust.  “For more than two decades,” Donna Ockenden wrote, “they [famiies] have tried to raise concerns but were brushed aside, ignored and not listened to.” But why should patients and families have had to show that kind of courage in the first place? Instead of seeing patient feedback as a foundation stone of high quality, evidence based care, healthcare providers too often see it as a threat writes Miles Sibley in this BMJ Editorial.
  14. News Article
    Poor culture and leadership must be addressed if we are to make our maternity services the safest place to give birth. This statement from the Royal College of Midwives (RCM) came as the final report of the largest ever review of NHS maternity services was published. The RCM acknowledged that the pain and suffering of the families had been worsened by having to fight for answers and vowed to work with NHS bodies and other professional organisations to ensure lessons are learned from these tragic failings. Today the RCM has pledged to continue its work to be part of the solution to safety improvements and support its members to do the same not only at Shrewsbury and Telford NHS Trust, but throughout all maternity services across the UK. Commenting, the Royal College of Midwives’ (RCM) Chief Executive, Gill Walton said: “It is heartbreaking that this report only came about because of the determination of the families. We owe them a debt that I fear can never be repaid. What we can do - all of us who are involved in maternity services – is work together to ensure we listen, and we learn from this and ensure that women and families have trust in their care." “This review must be a turning point for all those working in maternity services. The actions recommended are measured and sensible and reflect much of what the RCM has been calling for. We hope that those in a position to enact them – NHS England and the Department for Health & Social Care – will do so in partnership with organisations like ours and with haste.” "A poor working culture, where staff were afraid to raise concerns, has been cited by the report as a key factor in many of the cases. Earlier this year the RCM called for a seismic NHS cultural shift to improve maternity safety as it published guidance for its members to raise concerns about maternity care which outlined steps staff can take and what to do if they feel they are not being listened to or their concerns are ignored." Read full story Source: Royal College of Midwives, 30 March 2022
  15. News Article
    Sajid Javid has issued an apology for the maternity service failings reported at Shrewsbury and Telford Hospital NHS Trust. The health secretary spoke in the Commons on Wednesday after an independent inquiry into the UK’s biggest maternity scandal found that 201 babies and nine mothers could have - or would have - survived if the NHS trust had provided better care. Speaking in the Commons, the health secretary said Donna Ockenden - a maternity expert who led the report - told him about “basic oversights” at “every level of patient care” at the trust. He said the report “has given a voice at last to those families who were ignored and so grievously wronged”. Javid said the report painted a tragic and harrowing picture of repeated failures in care over two decades which led to unimaginable trauma for so many people. Rather than moments of joy and happiness for these families their experience of maternity care was one of tragedy and distress and the effects of these failures were felt across families, communities and generations. The cases in this report are stark and deeply upsetting. Mr Javid offered reassurances that the individuals who are responsible for the “serious and repeated failures” will be held to account. Read full story and Sajid Javid's statement Source: The Independent, 30 March 2022
  16. News Article
    A policy ‘at the heart’ of NHS England’s efforts to improve maternity care is under question after being sharply criticised by an independent inquiry, and is the subject of major tensions within NHSE and midwifery, HSJ understands. The Ockenden report into major care failings at Shrewsbury and Telford Hospital Trust included 15 “immediate actions” for all maternity services in England, which government has accepted and said it would begin implementation. However, one of these relates to the “continuity of carer” model, which NHS England has championed since 2017, when it was described as “at the heart of” its national plans for improving maternity care and outcomes. The model intends to give women “dedicated support” from the same midwifery team throughout their pregnancy, with claimed benefits including improved outcomes, with a particular focus on some minority groups. However, Ms Ockenden indicated its implementation in recent years had stretched staffing, and therefore harmed quality and safety overall, and also appeared to question whether the model was evidenced. Some midwifery leaders are advocates for the model, but others have described how it can result in awful working patterns, with concerns it is causing some staff to leave the profession. Royal College of Midwives director for professional midwifery Mary Ross-Davie told HSJ: “With the right resources and the right number of midwives, CoC can have a positive impact on maternity care – but in too many trusts and boards this is simply not the situation. We are really pleased, therefore, to see that the review team has echoed the RCM’s recommendations around the suspension of continuity of carer where too few staff puts safe deployment at risk.” She said the model was “something to which many maternity services aspire, particularly for women who need enhanced monitoring throughout their pregnancy to deliver better outcomes for them and their baby”. Helen Hughes, chief executive of Patient Safety Learning charity, said that although it had heard positive feedback that the model can improve outcomes, there must also be a “robust assessment of the safety impact of implementing such changes and the sources and staffing in place to deliver this”. “Otherwise the core intentions and benefits will be lost,” Ms Hughes said. Read full story (paywalled) Source: HSJ, 31 March 2022 Further reading Midwifery Continuity of Carer: What does good look like? Midwifery Continuity of Carer: Frontline insights The benefits of Continuity of Carer: a midwife’s personal reflection
  17. Content Article
    This is the transcript of a statement given in the House of Commons by the Secretary of State for Health and Social Care, Sajid Javid MP, in response to the publication of the final report of the Ockenden Review. In the statement he makes a commitment that the local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations made by the Review. This is followed by questions from MPs in the Chamber and Mr Javid's responses.
  18. News Article
    A shortage of more than 2,000 midwives means women and babies will remain at risk of unsafe care in the NHS despite an inquiry into the biggest maternity scandal in its history, health leaders have warned. A landmark review of Shrewsbury and Telford hospital NHS trust, led by the maternity expert Donna Ockenden, will publish its final findings on Wednesday with significant implications for maternity care across the UK. The inquiry, which has examined more than 1,800 cases over two decades, is expected to conclude that hundreds of babies died or were seriously disabled because of mistakes at the NHS trust, and call for changes. But NHS and midwifery officials said they fear a growing shortage of NHS maternity staff means trusts may be unable to meet new standards set out in the report. “I am deeply worried when senior staff are saying they cannot meet the recommendations in the Ockenden review which are vital to ensuring women and babies get the safest possible maternity care,” said Gill Walton, chief executive of the Royal College of Midwives (RCM). The number of midwives has fallen to 26,901, according to NHS England figures published last month, from 27,272 a year ago. The RCM says the fall in numbers adds to an existing shortage of more than 2,000 staff. Experts said the shortage was caused by the NHS struggling to attract new midwives while losing existing staff, who felt overworked and fed up at being spread too thinly across maternity wards. Read full story Source: The Guardian, 29 March 2022
  19. Content Article
    In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).
  20. News Article
    A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022
  21. Content Article
    The Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
  22. Content Article
    The concept of woman-centred care is at the core of midwifery care and midwives have a key role as advocates and facilitators of women’s choices. This briefing from the Royal College of Midwives provides guiding principles and support for midwives in facilitating personalised care and women’s choices, including when those fall outside clinical recommendations.
  23. Content Article
    Jail can never be a safe place to be pregnant but the flouting of rules makes things worse. No woman should suffer as I did, writes Anna Harley in this Guardian article.
  24. News Article
    The Royal College of Obstetricians and Gynaecologists (RCOG) has called for the immediate suspension of charging for NHS maternity care for migrant women because members say this government policy is harming the health of pregnant women and their babies. It is the first time the health professionals’ body has issued a position statement on this issue. The charity Maternity Action and the Royal College of Midwives have long expressed concern about the impact of NHS charging on this group of women. Charging forms a key plank of the Home Office’s hostile environment for migrants. The government says the charging policy is in place to deter health tourism but medics treating migrant pregnant women say there is little evidence that previously free NHS maternity care for all attracted health tourists. According to the 2019 MBRRACE-UK confidential inquiry into maternal deaths, three women were found to have died between 2015 and 2017 who may have been reluctant to access maternity care due to fears about charging and impact on their immigration status. Dr Brenda Kelly, an NHS consultant obstetrician working in Oxford, treats many pregnant migrant women. She is calling for the barriers to them accessing maternity care to be removed urgently. She described the case of one migrant woman who arrived in A&E shortly before delivering a stillborn baby. The woman had been fearful of coming forward for antenatal care although she was suffering from multiple, pregnancy-related health problems. “I hope I never have to hear cries like that woman’s cries ever again,” said Kelly. “The way to safeguard these women is to build up trust. If they are landed with a bill of several thousand pounds they will disengage. They are not health tourists, they are desperate. The commitment to maternal health equity means ending charges for maternity care. The time for action is now.” Read full story Source: The Guardian, 27 March 2022
  25. Content Article
    1 in 5 women are affected by maternal mental health problems, which are the leading cause of maternal death in the first postnatal year. This report by the Maternal Mental Health Alliance (MMHA) estimates the costs and benefits of a model of care which could give women’s mental health the same priority as their physical health during the perinatal period. The model focuses on the essential role of midwives and health visitors and would allow for women’s mental wellbeing to be accurately assessed at every routine contact and suitable treatments to be offered. It is based on research commissioned by MMHA and conducted by the London School of Economics and Political Science (LSE), which estimates that making changes to standard practice could mean £52 million in NHS savings and quality of life improvements worth £437 million.
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