Nottingham Maternity Review Sparks Commitment to Change
Anthony May, chief executive of Nottingham University Hospitals (NUH) NHS Trust, expressed that he was "shocked and upset" by the findings of the largest maternity review in NHS history, which was published on Wednesday. The review detailed "deeply embedded systemic failures" that resulted in hundreds of deaths and avoidable harm to mothers and babies.
Following the announcement, May stated he left with a "renewed commitment" to ongoing improvement, including the implementation of all essential actions outlined in Donna Ockenden's report. However, he acknowledged that the trust had not always "met their aspirations" regarding staff accountability for failings.
Background and Scope of the Review
The independent maternity review, led by senior midwife Donna Ockenden, formally commenced on 1 September 2022. It involved contributions from approximately 2,500 families and over 800 current and former staff members.
The review identified "potentially avoidable" outcomes in 520 cases involving mothers and babies. It further concluded that different care might have changed the outcomes for 260 babies, including 155 who died and 105 who suffered serious brain injuries due to substandard care, according to the review team speaking to the BBC.
Additionally, the report highlighted a "bullying and toxic" workplace culture that inhibited staff from raising concerns. Ockenden noted that a small number of influential leaders had "infected the unit."
Response and Actions by NUH
NUH was provided with a list of mandatory actions to address the failures identified by the review. At a board meeting on Thursday, the NUH board accepted the report's findings and committed to making improvements.
In an interview with the BBC, May pledged to remain in his role for the next two years to oversee the necessary changes. He described the publication of the review as a "watershed moment."
"Anyone who's in the room yesterday, as I was, would have been shocked and upset and although Donna has kept us up to date with her findings as she has gone along, it was still shocking and upsetting.
"I was also greatly affected, as I have been over the past four years, by the courage of the families who have told their experiences time and time again, because they want us to learn and do better and I came away with a renewed commitment to continue to improve."
May emphasized that engaging with both the report and affected families is crucial to effectively addressing the issues.
"We will implement the immediate and essential actions - many of which because Donna has fed them back to us over the years of the review.
"So for example, we've already implemented Martha's Rule in our maternity services and are one of the first in the country to do that.
"We absolutely must listen to women and families and the families have been good enough to share their experiences with us and I've met many of them.
"If we don't listen to them, we won't continue to improve,"
he said.
Family Perspectives and Calls for Accountability
Natalie and David Needham, whose son Kouper died hours after being discharged in July 2019, described the extent of the failures as shocking.
David Needham said: "[The report] was just really powerful and shocking at the same time.
"Together I think we're much stronger - as a support group and going forward as well - but it was just so shocking some of the stories that were coming out.
"Even the majority of the core group families couldn't imagine."
Felicity Benyon, who experienced a wrongful bladder removal during an emergency hysterectomy, highlighted a significant concern.
"The fact that they knew," she said. "As a senior leadership team, as a governance team, they knew.
"They had so many investigations internally and externally, mums repeatedly saying 'something's not right, the care isn't right, this has happened to me', and they had whistleblowing staff.
"And yet they didn't do enough."
Leadership and Accountability Measures
The report indicated that 66 former and current senior colleagues were contacted by the trust's chief executive, with 37 responding and 35 interviewed as part of the review. However, some senior staff declined to participate.
In response, the government announced on Wednesday, as part of the extension of Martha's Rule, that NHS staff, past and present, who refuse to engage with future reviews could face up to two years in prison.
May said: "Accountability is an enormously important issue for the families. I know we don't always meet their aspirations, but it is important to us and we have acted on accountability.
"All the senior executives currently employed by the organisation I represent have engaged with Donna's review.
"I encouraged them to do that and they did.
"Those who have left the organisation may have made a different choice."
Additional Developments and Contact Information
A Learning and Improvement Board will be chaired by Labour MP Michelle Welsh, who experienced birth trauma at NUH in 2020.
Some families affected by the trust's failings have renewed calls for a statutory public inquiry into maternity services across England, emphasizing the need for accountability of individual staff and executives.
Members of the public are encouraged to share story ideas and follow updates via BBC Radio Nottingham and social media platforms. Contact details include an email at eastmidsnews@bbc.co.uk and a WhatsApp number 0808 100 2210.
