Nottingham Hospitals NHS Trust
Donna Ockenden has been appointed Chair of what is being considered the largest review of NHS maternity services in the UK to date in her review of Nottingham University Hospitals NHS Trust (the Trust). Dubbed the Ockenden Review, it replaces a previous investigation in to maternity services within Shrewsbury and Telford Hospital NHS Trust which concluded in March 2022 and highlighted a number of failings in its care.
The Review began in September 2022 following preliminary investigations and enquiries, including direct contact with affected families, and is anticipated to last around 18 months before a formal report is published.
The Review follows significant concerns regarding the quality and safety of care within the Trust and has been established in order to independently investigate negligence within services provided by the Trust in the last 10 years. It seeks to identify the systemic failures which have led to mothers and babies sustaining avoidable (catastrophic) injuries or death.
The full details of the Review can be found within the Terms of Reference document produced by the Review board – click here.
Categories of case
The Review has identified and set out 5 categories of case as the focus of the Review, these being:
- Term and intrapartum stillbirths
- Neonatal deaths from 24 weeks gestation that occur up to 28 days of life; the review team will also consider neonatal serious incident reports and neonatal never events
- Babies diagnosed with Hypoxic Ischemic Encephalopathy (Grade 2 & 3) and other significant hypoxic injury
- Maternal death up to 42 days post-partum
- Severe maternal harm to include cases such as all unexpected admission to ITU requiring ventilation, major obstetric hemorrhage e.g. cases where blood loss exceeds 3.5L, peri-partum hysterectomy, and other major surgical procedures arising from the maternity episode, cases of eclampsia and clinically significant cases of pulmonary embolus requiring further treatment
It was announced on Monday 10th July 2023, following the preliminary preparations, that 1,700 individual cases have been identified as relevant for the purposes of the Review and will form part of its investigation.
Giving NHS staff a voice
Ockenden has maintained a determination to thoroughly and robustly investigate clinical failures within the Trust and in doing so launched the Staff Voices initiative in October 2022 as part of the Review: a confidential channel allowing staff within the Trust to submit their concerns anonymously to the Review board. To date, over 250 NHS staff have come forward to assist the Review.
It seeks to give a voice to NHS staff who have raised historical concerns regarding the mismanagement of staff, individual patient care plans and services generally but were disregarded or ignored. Whilst it is not unique nor surprising to learn of understaffing within the NHS, it has previously been identified as a materially contributing factor in incidences of avoidable neglect, most notably following the tragic death of baby Wynter Andrews in September 2019.
Following the inquest of baby Wynter’s death at Queens Medical Centre, Nottingham, Coroner Laurinder Bower issued a robust Prevention of Future Deaths Report in September 2020 and within it raised grave concerns about the standard of care and the avoidable nature of the death, stating:
“Staff told me this was not the first time, nor the last time, that they have been asked to care for multiple families simultaneously, meaning that those families cannot receive the time, focus and dedication they require. Staff further told me that they have repeatedly raised their concerns about patient safety, but their concerns have been met with silence… Midwives spoke of their inability to professionally challenge plans made by medical staff, even in circumstances where they felt the plan might harm mother or baby.”
The negligence leading to baby Wynter’s death was sufficient such that criminal proceedings were successfully brought against the Trust and a fine of £800,000 was imposed. Speaking of baby Wynter’s death and the devastating impact it has had on her parents, Sarah and Gary, Ockenden said:
“Wynter’s death was an avoidable tragedy; put simply it should not have happened… We promise them (Sarah and Gary) that their voices will be heard and their experiences will make a difference.”
Continuing failures
Sadly, it is clear that failings within maternity services persist and the effect of these failings are tangible and devastating. Whilst the Review has adopted a forceful approach to its enquiries, it is little comfort to those who have already suffered traumatic losses as a result of what is clearly a pervasive and alarming set of failures within the NHS.
Child loss charity, Tommy’s, reports the stillbirth rate in England and Wales is up from 3.8 in 2020 to 4.1 in 2023. Data collected in 2022 also shows that UK women are 3 times more likely to die around the time of pregnancy than those in other countries, reflecting an increase in maternal mortality rates in comparison to previous years.
It is a sad reminder of the risks associated with maternal care, particularly for women from ethnic minority backgrounds who are subject to ethnic inequality in the provision of clinical care, with the same study identifying that women from ethnic minority backgrounds had a 50% greater risk of maternal mortality.
Rothera Bray Solicitors – Clinical Negligence Experts
Sadly, clinical negligence is not uncommon and loss following poor maternal care is not a matter with which Rothera Bray is unfamiliar. The Review has given cause for great concern and the publicity of the investigation has encouraged many families to come forward and talk about their experiences with the hopes of improving care for families in the future. For many, however, the fallout of their loss and grief is not linear nor straightforward and countless families continue to struggle – emotionally and financially – with finding closure and moving forward.
Rothera Bray have experience in supporting families through grief by seeking accountability for these failings which includes securing compensation. We are hopeful that the outcome of the Review will establish a foundation in which successful claims may be brought against the Trust and compensation be obtained.
If you or your family have made enquiries with, or your case is being investigated by, the Review, you can contact our expert clinical negligence team on 03456 465 465 or email enquiries@rotherabray.co.uk to discuss how we may be able to help and support you.
Review progress
Updates on the Review are posted on its website and can be accessed in multiple languages (including Urdu, Polish and Arabic) at https://www.ockendenmaternityreview.org.uk/#
The website also publishes intermittent announcements and contains information on the members of the Review board.
Support
Other avenues of support are available at:
Baby loss:
https://www.tommys.org/baby-loss-support
https://www.sands.org.uk/support-you
Bereavement support:
Support for NHS staff:
https://www.ockendenmaternityreview.org.uk/support-for-staff/
