“To do nothing is not an option.”

“There must be an end to investigations, reviews, and reports that do not lead to lasting meaningful change.”

Ockenden Report into Maternity Services at Shrewsbury and Telford NHS Trust, 10 Dec 2020

It’s been an historic day for the future of maternity safety.

This morning, I was presenting at a Public Policy Exchange webinar entitled Transforming UK Midwifery: Developing Maternity Services to Promote Quality, Safety and Stability. I was speaking about the contribution the third sector can make to improving maternity care in the UK, but also about my personal experiences of the good and bad of maternity care as a bereaved parent.

I followed some fantastic speakers from the maternity sector – from clinical practice, from the academic side of midwifery, and from the regulatory side. All had different, but hugely valuable, perspectives and insights into factors affecting the provision of safer maternity care.

As I was presenting, the Ockenden Report was published. Click here for the full report:

Jeremy Hunt – a former Health Secretary and now Chair of the Commons Health Select Committee – has this afternoon said, without a hint of hyperbole, that it “could become the biggest patient safety scandal ever for the NHS”. There are many local recommendations, and a number of national recommendations for immediate action.

Some of the incidents relayed in the report today are truly harrowing, but something else struck me as I read the report as both a bereaved father and as a campaigner in the world of maternity safety.

There’s nothing new. We’ve seen these findings before.

The Ockenden Report calls for maternity services to focus on “listening to women and families”.

So did the 2016 National Maternity Review.

The Ockenden Report calls for multi-disciplinary training and working.

So did the 2016 National Maternity Review.

So did the 2015 Kirkup Report.

The Ockenden Report calls for risk assessment during pregnancy.

So did the Kirkup Report.

The Ockenden Report calls for local and regional collaboration between trusts.

So did the Kirkup Report.

The Ockenden Report calls for improved monitoring of fetal wellbeing.

The Saving Babies Lives Care Bundle in 2016 laid out the importance of this.

How many more reports into babies’ deaths have to say the same thing before people start listening?

Even in 2016, when we launched Saving Babies Lives, there was a recognition that the measures designed to reduce preventable stillbirths weren’t new ideas – reduce smoking during pregnancy, educate women better about the importance of their baby’s movements, identify babies that are small for gestational age, and improve monitoring during labour.

Continuity of carer saves lives by promoting a stronger bond of trust between care giver and woman.

Customised growth charts help us identify babies that are small, so we can take appropriate steps to ensure their safety.

Robyn & Hallie’s customised growth chart, showing Henry’s birth weight

So why do we keep re-inventing the wheel?

“Recommendations are of limited use if they are not implemented.”

Bereaved parents don’t expect the impossible – no review can bring our children back – but they DO, as the authors of today’s report have said, “want the system to learn, so as to ensure that any identified failings in their care are not repeated.”

The key to ensuring that we won’t be working our way through another such report in four years time is a cultural shift. A shift away from a culture of blame that disincentivises individuals to admit to errors or point out flaws in the care systems in which they operate – a shift towards openness and transparency, to a transformational culture that’s about continual improvement.

It’s not acceptable to say that care is being provided a certain way because “it’s always been done that way”.

Personalised, patient-centred care isn’t a concept that’s unique to maternity, and it’s not a new concept in healthcare. To finally bring about change, people need to start collaborating more effectively – both internally and with outside agencies.

“Everyone has a part to play. To do nothing is not an option.”

So let’s open up, let’s start working together, and let’s bring about real change. Great strides have been made in the last few years. Today’s report shouldn’t cause us to retreat into our shells due to the horrific nature of its findings. It should lead us to renew and redouble our efforts to bring about change, make embedded adjustments to working practices, and help more babies arrive safely into the world.

As the world focused on the Ockenden Report, the 2018 MBRRACE data was published, showing another significant reduction in stillbirth and neonatal death rates across the country.

Summary findings of the MBRRACE 2018 Perinatal Surveillance Data

Progress is being made. In 2014, when Henry died, the stillbirth rate was identical to that of 1992. There’s been a huge reduction between then and 2018.

The new measures are working. Let’s make sure they carry on doing so. Let’s learn from the Ockenden Report and build on it, not get thrown off by it.

As bereaved parents we all wish that our baby was the last one whose death was preventable.

Let’s make sure that this is the last report whose findings are preventable.

“There must be an end to investigations, reviews, and reports that do not lead to lasting, meaningful change.”

Donna Ockenden, 10 Dec 2020

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