The Ockenden report of the review into maternity and neonatal services at Nottingham University Hospitals NHS Trust was published last week and makes shocking and distressing reading.
Prompted by the experiences of numerous families who have suffered severe harm, loss of either baby or mother, and deep psychological distress as a result of the poor quality of the maternity provision, the review investigated the quality of maternity care at the Trust.
Through analysis of records and responses from more than 2,500 families as well as listening to staff members and clinicians, the review has found consistent failings across numerous aspects of maternity care.
Repeated references within the report to avoidable harm, ignored concerns, ‘a bullying and toxic culture’, staffing challenges and shortages, failures to listen to women, failures to investigate incidents and inconsistent application of national guidelines all combine to paint a picture of systemic dysfunction, leaving new mothers and their babies vulnerable to harm.
The ‘Immediate and Essential Actions’ identified by the report necessary to improve care address a wide range of issues including listening to women, safe staffing, training, risk assessment, incident investigation and culture.
Donna Ockenden, who led the review, offered hope for improvements in maternity care at Nottingham and across the UK ‘but only if there is unwavering commitment to accountability, learning, transparency and kindness at every level of the system’.
Optimistically, the review also noted examples of excellent care and that improvements are being made in some areas.
However, substandard maternity care can be life-changing.
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