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Failure to work collaboratively and learn from incidents led to deaths of babies and mothers at Shrewsbury and Telford trust, review finds

BMJ 2022; 376 doi: (Published 31 March 2022) Cite this as: BMJ 2022;376:o858
  1. Clare Dyer
  1. The BMJ

Around 200 babies and nine mothers would or might have survived had they received the right care from Shrewsbury and Telford Hospital NHS Trust, a damning review of the trust’s maternity services has concluded.1

The Ockenden review, which looked at the cases of nearly 1500 families who experienced maternal or neonatal harm mainly from 2000 to 2019, found repeated shortcomings and failings throughout the services over the past two decades. These included a failure to follow national clinical guidelines on a range of issues such as monitoring fetal heart rate or maternal blood pressure, management of gestational diabetes, and resuscitation.

The review found a longstanding failure of clinical governance, where a “continual churn” of the executive team and board led to an inability to deliver improvement. A shortage of midwives and doctors meant that staff were spread too thinly. Staff described a culture of “them and us” between midwives and obstetricians, with midwives frightened to escalate their concerns to doctors. Even when cases were escalated senior clinicians did not always take action.

The failure to follow guidelines, combined with delays in escalation and a lack of collaborative working across disciplines, “resulted in the many poor outcomes experienced by mothers or their babies, such as sepsis, hypoxic ischaemic encephalopathy and unfortunately death,” said the report.

In hundreds of cases, including deaths, the trust had not carried out a serious incident investigation, …

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