“Kate was the most beautiful baby you’ve ever seen … when Kate was born, quite literally, a light lifted inside me, it was so physical the love I felt … and that love turned into sheer determination.” Six hours after she was born at Ludlow community hospital in 2009, Kate Stanton-Davies was dead. If not for the “sheer determination” described this week by her mother, Rhiannon Davies, the Ockenden report into maternity care may never have come about.
Along with Kate’s father, Peter Stanton, and Colin and Kayleigh Griffiths – the parents of another newborn baby, Pippa, who died in 2016 – Ms Davies pushed and pushed for an independent review of the service offered to mothers giving birth by Shrewsbury and Telford NHS Trust. This week’s publication of what are described as “emerging findings” is only a staging post, based on 250 cases; the total number being examined has risen to 1,862 since the report was commissioned by the then health secretary, Jeremy Hunt.
The snapshot it offers of what went wrong between 2000 and 2019, when 13 women and at least 42 babies died, while hundreds were injured, is vivid and alarming – an effect magnified by the fact that some of the findings are familiar. Like the 2015 review of maternity failures at Morecambe Bay, this report points to a culture surrounding labour wards in which midwives at times appear to regard doctors more as rivals than colleagues. A reluctance to deliver babies by caesarian section was one problem; in a table comparing data from Shrewsbury with neighbouring trusts and England overall, the disparity of 8-12% is glaring.
There were shocking failures too in the use of oxytocin and fetal heart monitoring, while cases that became complicated were not reliably escalated. As in Morecambe, a commitment to non-medicalised, midwife-led childbirth appears to have taken precedence over evidence and safety. That mothers were blamed when things went wrong, and bereaved families treated unkindly, shows how an approach that is meant to be built around the idea of birth as a natural process can turn out to be callous and self-serving too.
“Women are not aware of the risks,” Ms Davies said, and in too many cases she is right. Giving birth can be dangerous, and regularly leads to complications including heavy bleeding and perineal tearing (which can cause infections and incontinence). Women must, as the report says, be supported to make choices informed by facts. This does not mean that the pendulum should swing away from midwife-led care, back to a model where obstetricians are always in charge. On the contrary, blaming Shrewsbury’s failures on midwifery would be a cop-out. Anaesthetists, including consultants, were also culpable for failings such as not turning up when called. Too often, junior doctors were left in charge.
Big improvements to multidisciplinary training and working are among the report’s calls to action. Silos of doctors, nurses and midwives belong in the past. Detailed scrutiny of the trust’s governance will come in next year’s final report and is likely to be devastating (it has had eight chief executives since 2010). As in other similar instances, the institution’s refusal to admit shortcomings was hugely damaging. Not only did this increase grief-stricken people’s suffering; it also meant that lessons were not learned.
What is encouraging is that the report sees a clear path to improvement, with a role for regulators and professional bodies as well as regional oversight. The health secretary, Matt Hancock, said on Thursday that he would study the report “very, very closely”. The families who depend on these services cannot wait. With first Morecambe and now Shrewsbury, it is clear that problems with maternity care in England go wider than a single hospital or trust. Having entrusted Donna Ockenden, herself a midwife, and her team of clinical experts with this review, the government must now take their advice.