The Ockenden Review

Introduction

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 were 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 resources 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 upon 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.

Local actions for learning — obstetric anaesthesia

The Ockenden Review identified the following actions in this area.

• Obstetric anaesthetists are an integral part of the maternity team and must be considered as such. The maternity and anaesthetic service must ensure that obstetric anaesthetists are completely integrated into the maternity multidisciplinary team and must ensure attendance and active participation in relevant team meetings, audits, Serious Incident reviews, regular ward rounds and multidisciplinary training.
• Obstetric anaesthetists must be proactive and make positive contributions to team learning and the improvement of clinical standards. Where there is apparent disengagement from the maternity service the obstetric anaesthetists themselves must insist they are involved and not remain on the periphery, as the review team have observed in a number of cases reviewed.
• Obstetric anaesthetists and departments of anaesthesia must regularly review their current clinical guidelines to ensure they meet best practice standards in line with the national and local guidelines published by the RCoA and the OAA. Adherence to these by all obstetric anaesthetic staff working on labour wards and elsewhere must be regularly audited. Any changes to clinical guidelines must be communicated and necessary training be provided to the midwifery and obstetric teams.
• Obstetric anaesthesia services at the Trust must develop or review the existing guidelines for escalation to the consultant on-call. This must include specific guidance for consultant attendance. Consultant anaesthetists covering labour wards or the wider maternity services must have sufficient clinical expertise and be easily contactable for all staff on the delivery suite. The guidelines must be in keeping with national guidelines and ratified by the Anaesthetic and Obstetric Service with support from the Trust executive.
• The service must use current quality improvement methodology to audit and improve the clinical performance of obstetric anaesthesia services in line with the recently published RCoA 2020 ‘Guidelines for Provision of Anaesthetic Services’, section 7 ‘Obstetric Practice’ 27.
• The Trust must ensure appropriately trained and appropriately senior/ experienced anaesthetic staff participate in maternal incident investigations and that there is dissemination of learning from adverse events.
• The service must ensure mandatory and regular participation for all anaesthetic staff working on labour wards and the maternity services in multidisciplinary team training for frequent obstetric emergencies.

Local actions for learning — neonatal service

The Ockenden Review identified the following actions in this area.

• Medical and nursing notes must be combined; where they are kept separately there is the potential for important information not to be shared between all members of the clinical team. Daily clinical records, particularly for patients receiving intensive care, must be recorded using a structured format to ensure all important issues are addressed.
• There must be clearly documented early consultation with a neonatal intensive care unit (often referred to as tertiary units) for all babies born on a local neonatal unit who require intensive care.
• The neonatal unit should not undertake even short term intensive care, (except while awaiting a neonatal transfer service), if they cannot make arrangements for 24 hours on-site, immediate availability at either tier 2, (a registrar grade doctor with training in neonatology or an advanced neonatal nurse practitioner) or tier 3, (a neonatal consultant), with sole duties on the neonatal unit.
• There was some evidence of outdated neonatal practice at the Trust. Consultant neonatologists and ANNPs must have the opportunity of regular observational attachments at another neonatal intensive care unit.