A REPORT on serious failures at Shrewsbury and Telford NHS Trust represents a “dark day for maternity services”, says The Royal College of Obstetricians and Gynaecologists (RCOG).
The inquiry led by senior midwife Donna Ockenden reviewed 1,486 cases from 1973 to 2020 and identified failures to follow national clinical guidelines for monitoring of fetal heart rate, maternal blood pressure, management of gestational diabetes or resuscitation. These, combined with delays in escalation and failure to work collaboratively across disciplines, resulted in numerous cases of sepsis, hypoxic ischemic encephalopathy (HIE) and death.
The review considered 498 cases of stillbirth and found that one in four had significant or major concerns in maternity care that, if managed appropriately, “might or would have resulted in a different outcome”.
Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, commented: “We welcome the findings and recommendations of the independent review, and are committed to continuing our work to ensure that every woman and their baby has the best possible care and maternity experience, whilst reflecting on the uncomfortable truths contained in this report.
“Above all, our sympathies go out to all of the families who have experienced tragic maternity outcomes. Each maternal death, and the death or injury to a baby is devastating, and we owe it to all those affected by these tragedies to act swiftly on the recommendations to ensure these are not repeated.
"Our focus must now be on translating learning into practice, and joining up current programmes and resources within the maternity system to promote personalised care.
“The report contains an extensive number of local actions for learning for the Trust which must be taken forward with decisive action and kind and compassionate leadership. It also includes immediate and essential actions for all maternity services. Together with the Royal College of Midwives and other medical organisations and charities dedicated to the safety of pregnant women and their babies, the RCOG will look in detail at the report's findings and its recommendations and will embrace together the changes necessary to implement them.
“We recognise that many doctors and midwives reading this report today will feel demoralised and as leaders of the profession, we are committed to supporting our members and allied health professionals to deliver the best care. This needs real and total commitment from our government and the NHS at every level to provide adequate staffing, training and the ability to learn from every incident to enable doctors and midwives help every women and family have a safe birth.”
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