Shropshire maternity scandal: Downgraded review method hid true scale of hospital failings
The true scale of serious incidents involved in the Shropshire maternity scandal was hidden by a downgraded review method, it has been revealed.
Donna Ockenden's review of maternity services at Shrewsbury & Telford Hospital NHS Trust (SaTH), uncovered a series of shocking findings over how hundreds of families were failed over nearly 20 years.
Serious questions have been raised over why the problems were allowed to persist for so long, and the report concludes that the number of issues within the maternity services were hidden due to the use of a trust-only review method.
The report, which concluded that more than 200 babies could have survived if they had received better care at the trust, found a "concerning and repeated culture" that serious incidents were "inappropriately downgraded", to "avoid external scrutiny".
Instead of the 'Serious Incident' (SI) process, which resulted in an incident being reported to NHS England and local clinical commissioning groups, the trust used its own system called a 'high risk case review' (HRCR) for some incidents. These were not reported to either body.
Mrs Ockenden's review found the HRCR process, which is no longer used, "was less robust, varied considerably in quality and lacked the rigour and transparency of an SI investigation".
She specifically outlines how its use hid some of the problems in the maternity service, with the report stating: "The review team saw that frequently an early assessment was made by the maternity service that there was no act or omission in care, which meant that the investigation was downgraded to a HRCR. This meant that the true scale of serious incidents within maternity services at the Trust went unknown over a long period of time."
The report details how at a meeting it was explained that the trust-only HRCR process did not attract the same attention as the SI reviews.
A transcript of the meeting said: "A high risk case review has a very similar process, but it doesn't get reported to our non-executive, Health England and Tom, Dick and Harry... an SI gets reported all over the patch as far as I can see".
Mrs Ockenden's report suggested that there was concern from other staff at the meeting – to the extent that they had asked for it to be recorded.
They said: "My experience of the way that some of the investigations have been run have led me to believe that I should record this."
The report details one distressing case, where a baby's skull was fractured, leaving it with brain injuries and long-term disabilities, that should have been the subject of an 'SI' but was instead reviewed under the HRCR process.
Mrs Ockenden's review concluded that the method meant that chances to prevent future similar tragedies were missed.
It said: "This practice of conducting an internal HRCR when an SI was required is illustrated by a family in 2015. This involved a baby born by instrumental delivery, which clearly fell outside national guidelines.
"This baby suffered significant skull fractures, brain injury and has ongoing long-term disabilities as a result. Despite this meeting national SI criteria as an act or omission in care which resulted in serious harm, the decision was made to conduct an HRCR instead.
"The HRCR did follow an root cause analysis (RCA) approach but the quality of the investigation was poor. It did not involve the family, did not identify the root causes but instead concentrated on the incidental findings and the mitigations.
"Seemingly, the action plan did not offer any learning to the Trust so that similar incidents were prevented from happening again in the future."
Mrs Ockenden's report said there were a number of deaths of babies and mothers which had not resulted in SI investigations when they should have.
It stated: "The review team however, found many examples of families who met the criteria to have a full SI investigation, but had an internal HRCR conducted instead. For example, between 2011 and 2019 there were a number of maternal deaths, stillbirths, neonatal deaths and babies born with HIE where an HRCR was conducted.
"Where these cases correctly underwent a SI investigation, rather than an HRCR, the subsequent investigations were often found by the review team to be of poor quality."
The report also outlines how the HRCR process failed to get the answers families needed.
It states: "In many cases an HRCR failed to identify why the incident occurred, meaning that many learning opportunities were missed. Confusingly, the HRCR investigations often used phrases such as 'Root cause Outcome', 'RCA meeting' and 'RCA discussion', when in fact a root cause analysis was often not performed.
"Failing to do this properly meant that families were not given the answers they sought and deserves, the trust did not identify the underlying issues that led to the incident occurring and lessons were not learnt, so increasing the risk of further harm to families under the care of the trust."
