A robust and funded maternity workforce plan for England is urgently needed to prevent serious failures of care in maternity services, such as those identified at Shrewsbury and Telford

Hospital NHS Trust, an independent review has concluded. The final report of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, published today,

has called for a multi-year investment plan for maternity services to ensure provision of a well-staffed maternity workforce and to address the present and future requirements for midwives

and other maternity service staff. > “What is astounding is that for more than two decades these issues > have not been challenged internally" >  > Donna Ockenden The

Shrewsbury and Telford between 2000 and 2019. The review team spoke to the families involved and examined medical records. They also spoke to current and former members of staff. In this

final report, the review team found that none of 12 cases of maternal death at the trust had received care in-line with best practice. A quarter of nearly 500 cases of stillbirth had

significant or major concerns in their maternity care, and could potentially not have been stillborn if managed appropriately. And nearly a third of all babies who died within seven days of

birth had significant or major concerns in their maternity care that may have contributed to their deaths. RELATED ARTICLES  The reviewers found a failure to follow national clinical

guidelines such as those for monitoring foetal heart rate, maternal blood pressure, management of gestational diabetes or resuscitation. There were significant staffing and training gaps in

both the midwifery and medical workforce. Staff said they often felt fearful and stressed at work due to poor staffing levels. A culture of ‘them and us’ between midwifery and obstetric

staff meant midwives were often afraid to escalate concerns to consultants. And investigations of clinical incidents were not carried out to a high enough standard, and were sometimes not

carried out at all, leading to the same clinical failures being repeated multiple times. Chair of the review Donna Ockenden said: “The reasons for these failures are clear. There were not

enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. There was

a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. “What is astounding is that for more than two decades these issues have not been

challenged internally and the trust was not held to account by external bodies. This highlights that systemic change is needed locally, and nationally, to ensure that care provided to

families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding.” > "It 

is essential that families are heard, staff are able to speak up > and concerns are acted upon" >  > Andrea Sutcliffe Chief executive at Shrewsbury and Telford Hospital NHS

Trust, Louise Barnett, said: “Today’s report is deeply distressing, and, on behalf of all at the trust I offer our wholehearted apologies for the pain and distress that has been caused. “We

recognise the strength and determination shown by the women and families involved and take full responsibility for our failings as a trust.” She added: “We owe it to those families we

failed, those we care for today and in the future, and our valued colleagues providing that care, to continue to make the necessary improvements so we are delivering the best possible care

for the communities we serve.” The final report includes more than 60 recommendations for actions to be taken by Shrewsbury and Telford Hospital NHS Trust. It also includes 15

recommendations for changes to all maternity services in England. These include financing a safe maternity workforce, ensuring time for training for staff, and having a clear escalation and

mitigation policy when staffing levels are not met. Andrea Sutcliffe, chief executive and registrar at the Nursing and Midwifery Council, described the failures identified in the report as

“appalling”. “Each of these cases is a family tragedy, with some affected more than once. My heart goes out to all the women, babies and families whose lives have been so terribly impacted

by these shocking failings in care,” she said. She added that women and families should have been listened to and taken seriously far sooner. “Donna Ockenden and her team have undertaken

crucial work pointing the way to make sustainable improvements in maternity care. It is essential that families are heard, staff are able to speak up and concerns are acted upon,” she said.

The Royal College of Midwives’ (RCM) chief executive, Gill Walton, said: “This review must be a turning point for all those working in maternity services. The actions recommended are

measured and sensible and reflect much of what the RCM has been calling for.” She added that the report’s recommendations on addressing workforce shortages should be taken very seriously.

“It is not good enough that the government only pays attention to maternity services in the light of a tragedy such as happened at Shrewsbury and Telford,” she said. “If they truly value

maternity services – those who access them and those who work in them – they have to ensure not only that there are enough midwives, but that they have the right mix of skills, training and

experience to deliver care in the right place at the right time.” Speaking to parliament this afternoon, health and social care secretary Sajid Javid said that Shrewsbury and Telford

Hospital NHS Trust, NHS England, and the Department of Health and Social Care would be accepting all 84 recommendations made in the report. “This report has given a voice at last to those

families who were ignored and so grievously wronged and it provides a valuable blueprint for safety and safe maternity care in this country for years to come,” he said.