The Ockenden Review
The initial findings in the Review being based on 250 cases reviewed to date.
On 10 December 2020 the Ockenden Review was published which set out its findings further to an independent review of maternity services at Shrewsbury and Telford Hospitals NHS Trust. The review was formally authorised in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at the Trust”. Initially it was focused on 23 cases but was expanded significantly following contact from further families expressing concern at the treatment received. The total number of families involved in the final report is 1,862. The initial findings in the Review being based on 250 cases reviewed to date.
The Review detailed what was described as 7 immediate and essential actions to improve care and safety in maternity services to include:
- Enhanced safety to ensure collaborative working between Trusts to ensure that Serious Investigation Reports have both regional and local insight.
- Listening to women and their families.
- Staff training and working together.
- Managing complex pregnancies by use of clear and robust clinical pathways
- Completing risk assessments throughout pregnancy.
- Monitoring foetal wellbeing.
- Informed consent
The above themes are unfortunately familiar to those of us practicing in healthcare litigation but perhaps what is more useful and insightful for Trusts is the local actions for learning that the Report highlighted. Over the next few weeks we will therefore focus on these areas in turn to consider the wider assistance the report provides from a safety and learning perspective.
Local actions for learning - Maternity care
The Ockenden Review identified the following actions in this area:
- A thorough risk assessment must take place at the booking appointment and at every antenatal appointment to ensure that the plan of care remains appropriate.
- All members of the maternity team must provide women with accurate and contemporaneous evidence-based information as per national guidance to ensure that women can participate equally in all decision-making processes and make informed choices about their care. Women’s choices following a shared decision-making process must be respected.
- The maternity service at the Trust must appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion the development and improvement of the practice of fetal monitoring. Both of these must have enough time and resource to carry out their duties and must ensure that the service is compliant with the recommendations of Saving Babies Lives Care Bundle 220 (2019) and subsequent national guidelines, including regional peer-reviewed learning and assessment. These auditable recommendations must be considered by the Trust Board and as part of continued ongoing oversight that has to be provided regionally by the Local Maternity System (LMS) and Clinical Commissioning Group.
- Staff must use NICE Guidance (2017) on fetal monitoring for the management of all pregnancies and births in all settings. Any deviations from this guidance must be documented, agreed within a multidisciplinary framework and made available for audit and monitoring.
- The maternity department clinical governance structure and team must be appropriately resourced so that investigations of all cases with adverse outcomes take place in a timely manner.
- The maternity department clinical governance structure must include a multidisciplinary team structure, trust risk representation, clear auditable systems of identification and review of cases of potential harm, adverse outcomes and serious incidents in line with the NHS England Serious Incident Framework 2015.
- Consultant obstetricians must be directly involved and lead in the management of all complex pregnancies and labour.
- There must be a minimum of twice daily consultant-led ward rounds and night shift of each 24-hour period. The ward round must include the labour ward coordinator and must be multidisciplinary. In addition, the labour ward should have regular safety huddles and multidisciplinary handovers and in-situ simulation training.
- Complex cases in both the antenatal and postnatal wards need to be identified for consultant obstetric review on a daily basis.
- The use of oxytocin to induce and/or augment labour must adhere to national guidelines and include appropriate and continued risk assessment in both first and second stage labour. Continuous CTG monitoring is mandatory if oxytocin infusion is used in labour and must continue throughout any additional procedure in labour.
- The maternity service must appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion the development and improvement of the practice of bereavement care within maternity services at the Trust.
The Lead Midwife and Lead Obstetrician must adopt and implement the National Bereavement Care Pathway. The learning arising from the Ockenden Review is clearly transferable to other NHS Trusts across the country. Weightmans is committed to working collaboratively with NHS Trusts and NHS Resolution to ensure that the safety and learning from claims and reviews such as this is embedded into working practices, leading to improving the healthcare system.
Local actions for learning - Maternal deaths
The Ockenden Review identified the following actions in this area.
- The Trust must develop clear Standard Operational Procedures (SOP) for junior obstetric staff and midwives on when to involve the consultant obstetrician. There must be clear pathways for escalation to consultant obstetricians 24 hours a day, 7 days a week. Adherence to the SOP must be audited on an annual basis.
- Women with pre-existing medical co-morbidities must be seen in a timely manner by a multidisciplinary specialist team and an individual management plan formulated in agreement with the mother to be. This must include a pathway for referral to a specialist maternal medicine centre for consultation and/or continuation of care at an early stage of the pregnancy.
- There must be a named consultant with demonstrated expertise with overall responsibility for the care of high risk women during pregnancy, labour and birth and the post-natal period.