Trust in baby deaths scandal continuing to make strong progress

The top midwife at the health trust rocked by the Shropshire baby deaths scandal has said she is “very satisfied” with progress against the recommendations of the Ockenden reports.

Director of midwifery Annmarie Lawrence said the Shrewsbury and Telford Hospital NHS Trust (SaTH) remains ahead of schedule in addressing the actions set out in both the initial report from 2020 and the final report released last year.

As a result, she told the trust’s board of directors that the committee overseeing the implementation of the recommendations should meet less frequently from now on, to allow health bosses to focus on the remaining more “complex” actions.

Ms Lawrence said: “We are exceeding expectations and I am very satisfied with where we are currently.”

A report to the board showed that, as of last month, 47 of the 52 actions set out in the first Ockenden report had been delivered, with 45 of these rated ‘green’ as they had already been ‘evidenced and assured’.

From the 158 actions in the final report, 133 had been delivered of which 107 were ‘evidenced and assured’. Actions that have been delivered but are ‘not yet assured’ are rated amber, while those that have not yet been delivered are rated ‘red’.

Ms Lawrence said: “The picture presented in front of you is detailed as of July, however since this report was published we have made further improvements.

“We have changed a few of the red actions to amber and some of the amber actions to green.

“I am very, very satisfied with where we are.”

The board also received the minutes from the last three meetings of its Ockenden Review Assurance Committee (ORAC), which has been meeting monthly.

Ms Lawrence said: “I think it’s very sensible to move ORAC to bi-monthly now, giving us some additional time and capacity to support some of those more extensive actions, because some of those will take a significant amount of time to deliver.”

Board members noted that many of the red and amber rated actions were those that had been ‘de-scoped’ as being out of the trust’s hands, such as recommendations for the NHS nationally.

Dr Catriona McMahon, chair of the board, asked Ms Lawrence: “Are you confident that we are putting enough influence through the appropriate pathways into those actions, making sure they are going to be delivered in a sufficiently timely manner, given the complexity of many of them?

“Or are some of them so far out of our control that we really are recipients of the outcome?”

Ms Lawrence said the trust was in fact “leading the way in some of them”.

For example, one recommendation is for a new training package for band seven co-ordinators to be rolled out nationally. This is currently still rated ‘red’, despite the fact the training has been developed at SaTH.

Ms Lawrence said: “All of our band sevens have done the training, but it’s ‘not yet delivered’ because that programme we created isn’t yet the national programme.”

The Ockenden review examined maternity practices at SaTH over 20 years and found the failures there contributed to the deaths of 201 babies and nine mothers, and left other infants with life-changing injuries.