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In the baby deaths scandal, as in all these tragedies, the rot starts from the top

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OVER the last decade or so I have made it my job to read the full text of reports into various NHS disasters. This helps me pick out nuances often missed by the media. The most appropriate metaphor to describe the findings of the Ockenden Review into maternity services in Shrewsbury and Telford is that it was a complete plane crash.

Midwife Donna Ockenden and her team found that over a 20-year period 201 babies had died unnecessarily and 94 suffered brain damage with nine avoidable maternal deaths. This was due to appalling standards of maternity care right from the onset of pregnancy. There were inadequate risk assessments, incorrect clinical decisions and a failure to escalate concerns when problems arose. The findings of this report are truly dreadful.

But the crucial thing in such a report is not just what went wrong (catalogued in tragic detail), but to ascertain why it went wrong given all the checks and balances in the NHS. In paragraph 2.29 Ockenden focuses in on this. ‘Much of this review centres on the quality of the governance processes in place within the Trust, the quality of clinical incident investigations and any subsequent learning following clinical incident investigations.’

Consequently Chapter 4, headed Clinical Governance, gets straight to the heart of the matter and is key to understanding why things went so wrong. Having been myself involved in three governance reviews in hospital trusts I retain a particular interest in this subject.

Clinical Governance (CG) in the NHS is defined as ‘a system through which NHS organisations are accountable for continuously improving the quality of their services’. It encompasses ‘quality assurance, quality improvement, audit, and risk and incident management’. The scope of CG is far too broad for this short article, but at the heart is a culture of patient safety, and a safety incident is anything which leads to harm.

All hospital trusts will have extensive CG policies and procedures. Staff are encouraged to report any potentially harmful incidents, whether mild or major in a ‘no blame, transparent culture’ through a central reporting system which allows them to be reviewed and categorised according to severity. Each department will hold regular governance meetings to discuss these and, in theory, initiate policies in mitigation.

More simply it is: report all incidents, review and investigate, mitigate and change practice, learn and disseminate findings, and so improve safety and quality. Seems simple and it is something which the aviation industry has been practising for years resulting in it being the safest form of transport in the world. Much work has been done to integrate these systems into the NHS.

Ultimately statutory responsibility for CG rests with the Trust Board. On every board there will be an executive director with responsibility for oversight of CG, and to report to the board on significant issues.

But the key issue is the culture of the hospital trust – whether or not GC is genuinely embedded at ward level, and whether all staff are engaged – ‘ward to board’ as it is often termed.

The Ockenden Report highlights many failures in CG in the maternity unit. But in particular it focuses on the decision to downgrade Serious Incidences (SIs), which are breaches of care resulting in serious harm or death, to a local methodology termed High Risk Case Review (HRCR). An SI, according to national protocols, will generate a Root Cause Analysis (RCR) which is a highly structured process. The outcomes must be reported externally to NHS England and the local commissioners in line with national guidelines. However the problem was that this might make the trust look bad, especially since other external reviews had not identified any significant problems.

The review team found many cases who met the national criteria for a full SI review, but which were downgraded to an internal HRCR. These were much less rigorous in their approach, and the reviewers found that they were frequently inadequate, incomplete and lacked senior input, and crucially did not require external reporting.

The consequence was that the true nature of the harm to the mothers and babies was essentially concealed, and there was no opportunity to learn lessons and improve safety. It also prevented grieving parents being given honest answers.

In paragraph 4.10, based on interviews with the staff, it was stated: ‘One year we were criticised for over-reporting too many Serious Incident investigations . . . it was decided was that some of them shouldn’t have been reported as SIs, we were over-reporting.’

To me this is one of the most shocking statements in the report: ‘it was decided’! Who decided – a committee? A doctor? A senior midwife? The CEO or Medical Director? Ockenden was not able to find out although it first appeared in a policy document in 2014. But whoever it was is, in my opinion, deeply responsible and culpable.

When things go wrong, the basic issue is frequently a lack of engagement in clinical governance processes especially by senior staff. One of the reviews I was involved in concerned a newly appointed consultant surgeon. Soon after he started operating the nurses began to report complications, initially relatively minor but which grew more serious. These concerns were noted but not acted on. If they had been then the major catastrophe which followed may have been averted.

When we reviewed the minutes of the surgical governance meetings they were thin to say the least. Issues of concern would be highlighted, but no action taken since there was no one senior enough to take responsibility. Attendance, especially by the consultants, was very poor or non-existent. The stated reasons for non-attendance were the usual – too busy with the day job, unwilling to cancel clinics or operating lists. But it was clear that there was a fundamental unwillingness to engage with the investigative process of CG which led to disaster.

I believe that this is endemic in some, although not all, of the NHS. Individuals are defensive when challenged, and cover-ups and avoidance are common. Inappropriate confidence in one’s own ability is also a problem.

Ockenden also raised concerns about working relationships in the maternity unit. It found a culture of ‘us and them’ between the midwifery and the medical staff, especially the consultant obstetricians. This made it difficult for concerns to be escalated. Toxic relationships and poor team working are well recognised as a risk factor in clinical disasters and this frequently is a barrier to expressions of concern.

Paragraph 5.69: ‘The Trust consistently demonstrated negative behaviours and practices, resulting in many staff learning to accept poor standards as it became the cultural norm; this constitutes organisational abuse, similar to that found in the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013).’

When reviewing a different trust we were confronted by a completely dysfunctional relationship between a team of consultants, one of whom had a ‘strong personality, i.e. he was a total bastard, and staff were frightened of him. A good CEO or Medical Director may be able to manage these types, but more generally they get away with it, causing havoc. In this case no one had the balls to stand up to him, and this was a significant factor in the damage done. 

I have been re-reading the report into the maternity services of the Morecambe Bay NHS Trust by Dr Bill Kirkup and his team in March 2015.Seven years later Ockenden found exactly the same issues in Shrewsbury and Telford. Plus ca change! Did they learn nothing? Apparently not.

Ockenden again: ‘A staff member told the review team, “At a study day in 2016/2017, following the Kirkup report, a senior manager made the comment ‘we are not a Morecambe Bay’. I made the comment that we absolutely were a Morecambe Bay – a trust full of unhappy staff with ineffective poor leadership, looking to hide or ignore poor care and poor management”.’

This raises a further point made by Ockenden which has largely been missed by the media, but which was clearly a highly significant factor. The trust had an executive team which was constantly changing including ten board chairs from 2000 and ten CEOs to early 2020 of whom eight were in post between 2010 and current. This unexplained high turnover of senior executives indicated a hospital trust which was generally in turmoil. Culture comes from the top. If a board has patient safety high on its agenda clinical governance will be strong.

I visited a Trust where the total focus of the board was on cost-cutting virtually to the exclusion of all else (driven by NHS England), but the devastating effects of these cuts on staff and patients was somehow missed.

My point in this is that Donna Ockenden and her team have not found anything which has not been highlighted in multiple other reports, some better known than others. The same sorry issues come up again and again. This is deeply depressing: the NHS never seems to learn.

I watched the CEO of the trust being interviewed on TV the day the Ockenden report was released. Profuse in her apologies, she had the look of a frightened rabbit caught in the headlights. I doubt she will last much longer, nor will the current board. No senior management team can survive such a damaging report.

But when the new chair and CEO are appointed (or parachuted in by NHS England more likely) I strongly advise them to commission a full clinical governance review of the whole trust since it is highly likely that the culture Ockenden found in the maternity unit will be present throughout. Culture comes from the top.

So to those poor bereaved families who pushed for this review so that ‘nothing like this will ever happen again’, I have to say to you, sadly, don’t hold your breath.

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Dr Tom Goodfellow
Dr Tom Goodfellow
Tom Goodfellow is a retired NHS consultant radiologist who had a specialist interest in paediatrics and cancer diagnosis.

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