Shrewsbury and Telford – It’s Time to Start Listening to Women

Adapted from an article originally written in the Student Nursing Times. 

December 2019

This past month we have seen the publication of leaked reports from the Ockenden review regarding an investigation into Shrewsbury and Telford Hospital NHS Trust. Reports which are predicted to eclipse the Morecame Bay scandal at Cumbria’s Furness General Hospital (2004-2013).

Midwife Donna Ockenden has led an independent investigation into over 600 cases between 1979 and 2018, the largest maternity scandal in NHS history. These 600 cases include 42 fetal deaths, 3 maternal deaths and 50 cases of neonatal brain damage.

There have been several delays in bringing information to the public domain, and the latest delay is that an upcoming MBRRACE report Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK has been blocked from publication by NHS England until after the upcoming General Election. This report details trends in stillbirths, neonatal and maternal deaths and provides up to date information that is vital for healthcare professionals involved in maternity care to reflect on current practice and ensure watertight safety standards.

We were shocked and horrified at the publication of the Kirkup Report in 2015, which highlighted avoidable harm caused by uncollaborative working, poor communication and failure to learn from safety incidents. To quote Dr. Kirkup now “…two clinical organisational failures are not two one-offs: they point to an underlying systemic problem that may be latent in other units.”

Institutional failures in maternity care are not one off incidents, they are widespread and as a profession we must start listening to women. As students it is our responsibility to reflect on our curriculum and to provide feedback on whether we are being adequately prepared for practice; we need to demand that a thorough understanding of fear-based practice is included. We also need to be trained in responding to clinical errors as a basic part of our training, and we must start listening to women. Women are trying to tell us that life affecting procedures are carried out without consent, that they have experienced birth trauma and developed PTSD and that interventions are becoming so routine that they aren’t even offered a choice. If we can’t offer informed choice regarding routine procedures, how can we guarantee we can respond appropriately to women’s safety concerns?

In October two articles were published by the BJOG arguing for and against offering routine induction of labour at term for all women. The for article was made publically accessible and the against article was only made publically available after social media outcry.

This is the context to maternity care in Britain; that safety reports are deprioritised, that women are traumatised and ignored, and that only half an evidence story is told. We have to do better, and students must recognise that we have a vital role both now and in safe maternity care of the future.