Woman's Hour - Donna Ockenden and The Ockenden Review

Episode Date: March 31, 2022

Today we are dedicating the whole programme to the biggest maternity scandal in the NHS's history - leading to headlines across newspapers today stating childbirth is not safe for women in England. Those are the stark words of the midwife Donna Ockenden - the author of the long awaited Ockenden Review - published yesterday. Her mission? To find out what went on under the care of those working for the Shrewsbury and Telford Hospital NHS Trust over a 20 year period. She concluded 201 babies and nine mothers could have survived if the Trust had provided better care, learned from mistakes and crucially listened to women. Along with several other key guests she joins Emma to discuss her findings and where we go from here. Presenter Emma Barnett. Producer Kirsty StarkeyInterviewed Guest: Kayleigh Griffiths Interviewed Guest: Maria Caulfield Interviewed Guest: Donna Ockenden Interviewed Guest: Dr Jo Mountfield Interviewed Guest: Prof Soo Downe

This BBC podcast is supported by ads outside the UK. I'm Natalia Melman-Petrozzella, and from the BBC, this is Extreme Peak Danger. The most beautiful mountain in the world. If you die on the mountain, you stay on the mountain. This is the story of what happened when 11 climbers died on one of the world's deadliest mountains, K2, and of the risks we'll take to feel truly alive. If I tell all the details, you won't believe it anymore. Extreme, peak danger. Listen wherever you get your podcasts.

BBC Sounds. Music, radio, podcasts. Hello, I'm Emma Barnett and welcome to Woman's Hour from BBC Radio 4. Good morning and welcome to the programme. Today we are dedicating the whole of the programme to the biggest maternity scandal in the NHS's history, leading to headlines across the newspapers today stating, childbirth is not safe for women in England. Those are the stark words of the midwife, Donna Ockenden, the author of the long-awaited Ockenden Review, which was published yesterday.

Her mission? To find out what went on under the care of those working for the Shrewsbury and Telford Hospital NHS Trust over a 20-year period. She concluded 201 babies and nine mothers could have survived if the trust had provided better care, learned from mistakes, conducted proper investigations and, crucially, listened to women. Her report also revealed that some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, whilst others were starved of

oxygen and experienced life-changing brain injuries. Some women are also now living with life-changing conditions after serious birth injuries were not treated immediately. Donna Ockenden does not believe women in England are safe in childbirth until the actions of her report are implemented immediately. You'll hear from the woman herself shortly. Also on this special programme, you'll hear from one of the women who started the long and painful campaign to try and get to the bottom of exactly what was going on at that trust, Kayleigh Griffiths, who lost her daughter Pippa at just 31 hours old. Plus, I'll be joined by the Health Minister, Maria Caulfield, and the Consultant

Obstetrician, Dr. Jo Mountfield, the Vice President of the Royal College of Obstetricians and Gynaecologists. It's also worth noting that no one from the Shrewsbury and Telford Hospital NHS Trust is going to join me on the programme today, despite being invited. Today, we will be looking at what went wrong. How much of these problems not only occurring at this trust is down to an emphasis or was down to an emphasis on natural birth versus c-sections, how much it can be attributed to staff shortages, a particular culture, why staff don't feel safe speaking out still the truth today, why are women not being listened to and why did these failures take so long to come

to light? Of course, if you wish to be part of today's programme in any way, I'm always very up for listening to what you have to say. I hope you know that by now. You can text me here at Woman's Hour on 84844, text to charge your standard message rate, or on social media. We're at BBC Woman's Hour, or email me through the Woman's Hour website. But it only seems right that the first voice we hear from this morning is one of the women who fought for years to have this independent review. Having lost her daughter Pippa when she was just 31 hours old in 2016, Kayleigh Griffiths was convinced something hadn't been handled correctly after her home birth and

then in what she thought would be a thorough investigation. She wrote to Rhiannon Davis, whose daughter Kate had also died under the care of Shrewsbury and Telford Hospital Trust many years earlier in 2009, and knew she had been fighting for answers. They joined forces, and in a true story of sisterhood, fought a long and unwavering campaign for this review to come to light, to learn about why their girls and many others had died or suffered life-changing injuries. As Donna Ockenden delivered those conclusions at a hotel in Shropshire yesterday, Kayleigh and Rhiannon embraced in tears.

Well, just before coming on air, I did talk to Kayleigh Griffiths and I began by asking her how it felt for her and Rhiannon to have that report published. I think we'd both had a pretty, we'd had a very full week last week of lots and lots of press pre-release. And I know, you know, there was a lot of other stuff going on in the background and there was a point where we said we didn't know whether we could do it. And obviously Rhiannon comes from a lot longer distance than I do.

So to see her there and actually us both be there in the moment. And I think the enormity of the last couple of days hit us. And it was just, you know, we were there supporting each other and the other families. And it was just a really emotional moment. Because the story actually of you two, before we even get to what drove you to do this, you know, on behalf of your daughters, is actually also an amazing story of friendship and sisterhood. Yeah, absolutely. Obviously, I'd seen Rhiannon. Rhiannon's been fighting for 13 years, I think, since 2009. And I'd seen her fight and I, you know, obviously could see her strength.

And when I felt that things were going wrong for us, you know, obviously could see her strength. And when I felt that things were going wrong for us, you know, instantly my first thought was I must get in touch with that woman because, you know, her strength will help me with my own fight. And if you weren't going through enough, those years ago with her grief, you much more recently. And may I say how sorry I am for you and your family's loss because I think it's very important to make sure I do say that. You had to then fight to get this independent review. And this meant going through, as she had already been doing and you joined with that, going through cuttings, putting together reports, looking at coroner reports,

looking at media reports, looking at hower reports, looking at media reports, looking at how the trust had or hadn't responded to various complaints. I mean, this is a proper operation you took up. Yeah, and I think in the early days it was very much, I mean, to be honest, a lot of people have asked me about the early days and I struggle to recall them now. And I think that possibly it was a mechanism to keep myself busy to avoid what was really happening, because obviously I had those worries that it wasn't just me that it happened to. And yeah, it was very powerful to work through that with Rhiannon and uncover the 23. But of course, with the report and what we see from the findings, which looked over a 20-year period, the number is much bigger.

Donna Ockenden concluded 201 babies and nine mothers could have survived if the Trust had provided better care. When you hear that number, how does that make you feel? What is your response? For me, it's absolutely heartbreaking because, you know, if they'd have learnt the lessons from what people told them you know babies like Kate and Pippa would would be here and they should be here there's no reason why they shouldn't be here so to be able to give them a voice and actually to to make sure that

all these babies and all these mothers' families are heard. And I think it will make the difference to pregnant women to be able to find their voice as well if they have their own concerns. You know, they're more likely to speak out when they feel that there might be something wrong and actually get their voices heard. There'll be those listening who want to know how you were so sure something wasn't right about what had happened with your daughter with Pippa. What was that for you? So for me, it was I wanted to be involved in the serious incident investigation.

As an NHS professional in a different trust. I knew what the processes were and I knew that SAF weren't following those processes, which is what prompted me to make that contact with Rhiannon. And so you were uncomfortable as a member of the NHS, a different trust, with how Shrewsbury and Telford Hospital Trust were investigating or not the death of your daughter. Yeah, they did tell me there was an investigation ongoing, Telford Hospital Trust were investigating or not the death of your daughter? Yeah they were they were they did tell me there was an investigation ongoing but it was internal and if I wanted to be involved I could email any questions which I just wasn't happy with being as you know I was

one of the only people that had seen Pippa alive and I knew what had happened so I thought it was really important that actually they heard my story and learned from that. And with your story, what was the conclusion? Was responsibility taken? What has been said? Responsibility was taken by the trust that they'd failed to provide me with appropriate clinical assessment over the telephone and they hadn't provided me with guidance that would have prompted me to ask the right questions when I phoned the unit. And these were vital moments of course because your daughter had only just recently been born

and wasn't displaying at all well good, good health or health at all, was she? No, no, she wasn't. But unfortunately for me, not being a midwife or a doctor, I didn't realise how quickly a baby could deteriorate and, you know, exhibiting those symptoms. But obviously now I would do things things differently that comes up again and again with some of the women's stories that they also had been made to feel like somehow they should have been doing something different that somehow the blame was theirs yeah and I think you know

that's something we have all experienced to an extent blame placed on us. I know I was sort of placed the blame in that, well, she could have phoned back if she was that worried. So, yeah, to an extent, I think we were all made to feel guilty about our babies or, you know, the mother's deaths. How does yesterday's report help you in terms of moving forward um i think donna has set out fantastically this blueprint for what maternity services can do so you know going forward and i think that that report will make history um and it's just so important

that people listen to the stories and read the stories and and hear what has happened and just accept it and learn from it rather than fight against it and actually trusts up and down the country have been really um they've been really accepting of it and wanting to learn from it so you know i'm really really pleased with that and i'm you know i'm so thankful to donna and her team for for all they've done do you have faith improvements will happen because of your work because of this review because of all the campaigning you and your your fellow mothers have done and and fathers, of course, this has been a family effort. Yes, I think they will, because we're not in a society anymore where we can just hide, you know, poor care away.

Social media exists and people will find a way to find a voice. So, you know, it's really important that these reports like this are accepted and just put into place because otherwise they'll just pop up, you know, they'll continue to pop up. So it's important that hospital trusts read it and reflect on it. And it's important that the government make sure that there's funding and support in place for those trusts. Kayleigh Griffiths, thank you very much to her for talking to us this morning. Well, after the report was published, the one she'd fought so hard with other women

alongside for four, the Health Secretary Sajid Javid stood up in the House of Commons and said, this report is a devastating account of bedrooms that are empty, families that are bereft and loved ones taken before their time. We will act swiftly so that no families have to go through the same pain in the future. Well, I'm joined now by the Health Minister, Maria Caulfield, Minister for Primary Care and Patient Safety, which includes Women's Health and Maternity Services. Good morning. Good morning, Emma.

Donna Ockenden, the author of the review, and we'll be hearing from her in just a moment, said it was astounding that the Shrewsbury and Telford Hospital NHS Trust, that poor care was allowed to go on there for so long. What do you put it down to? Well, I think it is almost a perfect storm of failure. And I just want to just to thank Donna and her team so much for their hard work. Going through what we thought was just 20-odd cases at the time, which turned into over 1,000, was pretty harrowing and difficult.

And the support she's offered families who've gone through so much, she has done an amazing job. But just to reiterate what the Secretary of State said, that we can't apologise enough for what happened to those families and we urgently need to learn from those mistakes. But from Donna's work, there is a perfect storm of failure, whether it was the failure fundamentally to listen to women who were raising concerns, raising issues, or whether it's the staff themselves, you know, many of them didn't feel able or comfortable to raise safety concerns and describe a bullying culture that existed. Whether it's the scale of the systemic failure of, you know, a target driven approach to keep cesarean sections as low as possible was a significant failure as well. A perfect storm that of course your government has presided over. We have had a conservative government now for more than a decade and the

systems that you have in place are the systems that we trust to ensure that those are held accountable, those people in those positions of power. Do you know, and I just couldn't quite understand this myself, do you know what percentage of maternity services are rated outstanding in terms of providing safe care in England? Well, I don't have those figures to hand, but the report says over 20... Sorry, let's just pause on it for one moment. There's a reason I asked. One percent.

You are in charge of patient safety, particular responsibility for maternity services. If we only had one percent of schools at outstanding in this country, it would be of cause for concern. Why is it at that figure? So, you know, since I've come into post, you know, I recognise there are significant improvements that are needed in maternity services across the country. And we have put in some measures since Donna's interim report in 2020, and we're already seeing improvements. You know, stillbirth rates are reduced by 25%. Maternal deaths are also reducing.

Neonatal deaths are reducing by 36%. So we have put in some significant factors since Donna's interim report that will not just improve maternity services in Telford and Shrewsbury but across the country as a whole you know things like introducing the health safety investigation branch where patients staff anyone with concerns can go to or can trigger an investigation wasn't in place a few years ago and we're extending that by making it the special health authority later this year but also the funding we've put in 95 million pounds already to increase the number of midwives by over a thousand we announced earlier this week

increasing them doesn't necessarily solve the problem though does it should we get a bit into that because staffing was a major issue here the Royal College of Midwives are warning they can't implement the recommendations from this report, the actions as Donna wants them to be called, due to a staffing shortage of at least 2,000 midwives. Putting more money to get more midwives though doesn't actually work. Looking at the Conservative government's record of this, where successive health secretaries and prime ministers have been asked about this, it's actually the problem with retaining midwives. The most recent poll from the Royal College of Midwives showed that more than eight out of ten were concerned about staffing levels. Two thirds were not satisfied with the quality of care they are currently able to deliver. And here's the most alarming one. The highest level of dissatisfaction amongst midwives

came from midwives who'd only worked for five years or less in the NHS. So pouring money hasn't worked and won't work. You know, I disagree, Innocence. I've worked in the NHS for 25 years myself, and it's almost a vicious circle. If you haven't got enough midwives to start with, those that are there are under increasing pressure and retention of those midwives and it's important not just about the numbers but the skill mix of midwives having experienced midwives um you know

really does make a difference so in wanting to increase those numbers uh by over a thousand with that 95 million pounds and the 127 that we've announced this week will make a significant difference to both the recruitment but also the retention. And we're already seeing, as the Secretary of State pointed out in his statement yesterday, record numbers of both nursing and midwifery students coming, registering and starting courses. Now that obviously takes a little while for them to get trained and qualified, but we fully recognise that there needs to be more midwives on the ground and that's a way to improve safety. But you're not even filling the amount that has been asked for.

You're saying 1,000 and they're saying there's a shortage of at least 2,000. That's 1,000 extra. The number going into training colleges for this year is close to 4,000, but that obviously takes a while to filter through. That's a moot point. On the ground, they're saying there's a shortage of at least 2,000 midwives, at least, and you're offering to put 1,000 extra in. You have to be particularly good at maths to know, Minister, that that's not going to work. But it's not just about increasing the number of midwives, it's about creating a culture as well, because one of the key factors that Donna indicated in her report, and when you talk to midwives, and I talk to lots of midwives, the culture is as important as the numbers. When

they feel that they can't speak out if they're concerned about care, when they feel that there's a bullying culture in the system, and this was particularly prominent in Telford and Shrewsbury. It's as important that midwives are able to practice in a safe way, as well as the numbers of midwives that are in post. We're committed to increasing the number of midwives. We're putting extra money into it. We're seeing record numbers coming through for training. But when they're in post...

But they don't want to stay. But that's my point. When they're in in post it's absolutely important that they're supported and a bullying culture doesn't exist that they're able to get training and development and they feel safe uh to be able to practice and that didn't happen at shrewsbury and telford and donald very much pointed to a failure of leadership and governance at the Trust. And there are investigations both from professional bodies, but also the police into some of the actions that happened at the Trust. So as I said, it was the perfect storm of features that created these tragic events for families. Five men who ran the Trust from 2000 to 2019, the scope of the review, all left of their own accord to take jobs elsewhere in health, four in the NHS. Is it right no one was fired at the very top for the biggest maternity health scandal in the NHS's history?

No, I don't think so. And I think, Emma, you know, trying to be as candid with you as possible, We recognise that in a number of areas across the NHS, that improving the leadership and board members of any trust is crucial. Because where we've seen other investigations and reports, very often the leadership of a trust does not acknowledge there's been a problem, have tried to brush it under the carpet. That's why we've got the messenger review, which is particularly looking at leadership in the NHS, which will be reporting. What about this? What about this trust, though? This is what we're talking about. This report and this trust. Has anyone, has anyone senior lost their job over this? Well, I don't know if they've lost their job. They haven't lost the job, but there is a police investigation. I recognise that, but you seem very concerned about the NHS and the culture in it.

There's got to be culpability. So how has there not been that right at the top of a trust? We very much acknowledge, and Donna again pointed that out in the report, there was a series of leadership changes over that 20 year period where new CEOs would come in, would say to local MPs like Lucy Allen in Telford or Philip Dunn that, you know, these problems are historic, they're not happening now, and clearly that wasn't the case. And there was a significant change, not just of the CEO, but of the leadership team, who then, when the new team came in, kind of dismissed the problems and promised that things were different, and they absolutely weren't.

So whose fault's that? Whose fault that there's no ability to hold anyone to account? And it's very striking that no one from the Trust is on the programme this morning. I should also just point that out again. We did ask. But whose fault is that? The Conservative government's in charge all the way through this well look we were only we've been in charge for the last 10 years this is over 20 this is 20 years but but i'm talking about in the last 10 years

when we've got some of the reports and the feedback got statement from the care quality commission who who can make sure that heads do roll on this sort of thing because you need to have that culture don't you yeah absolutely and that's why we're bringing you're looking at the fit and proper person's test for people who sit on trust boards because you are absolutely right there needs to be an assurance that the people running these organizations are fit and proper uh to uh oversee the the care that's provided at their uh institution and that if there's problems that they are swift in dealing with them but we also saw that bodies like the cqc that were supposed to go in and assess and be independent the performance of the trust to look at not just the clinical care but the way the trust was being managed the way

safety problems were being highlighted and then acted upon they didn't do that and that again was a part of this perfect storm of failure why didn't you you know that then? Why haven't you and your colleagues, I mean, you also all change jobs quite regularly in all departments. You've only recently been in this role. But why wasn't that picked up on? Is the Care Quality Commission, the independent regulator of health and social care,

I'm just going to make sure everybody knows this, rated the maternity service in this trust as good in 2015? Is the Care Quality Commission fit for purpose, Minister? Yeah, I mean, that's something that the Secretary of State is absolutely looking at as a priority in the recommendations. The Secretary of State is accepting every single one of Donna's recommendations and the failure of outside bodies, independent bodies,

who are supposed to assess the safety of institutions is being looked at but what's your view what's your view i understand that the secretary of state who would of course very much like to have a woman's i've asked several times about different issues but we're grateful for your time this morning what is your view is the care quality commission you've worked in the nhs is it fit for purpose i think there have been significant changes to the care quality commission Commission in the last few years and I'm much more confident they and they do pick up mistakes you know we know of across the NHS they will pull out and I don't want to talk too much about other cases that are going on but

they have highlighted cases across the NHS where there's significant challenges and brought them to the attention of ministers, have taken contracts away from practitioners providing services for the NHS. So they very much do flag up cases now. So I'm confident. But there's clearly issues in the past where they didn't pick up these cases. It's not really in the past when it's 2015, is it,

to your point? The idea of saying it's historic, we're talking about a few years ago. Yeah, but they have made significant changes in the last couple of years, which gives me much more confidence. But why is your department, why hasn't your department picked up on,

for instance, these external watchdogs? Who is marking the homework of those who has failed to mark the homework of the doctors the nurses the bosses the culture whatever you want to call it in a trust that led to so many deaths of women children and life-altering injuries yeah and one of the things we are doing is introducing a new role called the patient safety commissioner who will have specific responsibility for looking over patient safety across the board. And whether it's the Cumberledge review, which highlighted some tragic outcomes in the NHS

and the failure to pick those up, or whether it's Donna Ockenden's report now. This is great now. I'm talking about then, which wasn't that far ago. Well, absolutely. Are you not ashamed that this has gone on on the conservative government's watch well it's not just the conservative government this has been over a 20-year period i accept that but for the last more than a decade it has been under your watch

and when i'm talking about shrewsbury rated as good in 2015 that is your watch yeah absolutely and we want you know we want these changes to happen we've apologized for the fact that you know these tragic events happened and we can't undo any of that but what we can do is learn the lessons from it the fact that you know women weren't being listened to by the trust that the staff who wanted to speak out either couldn't speak out or when they did speak out, weren't listened to, that the leadership of the trust denied that there was problems happening and didn't act on it, that the outside bodies who were supposed to be safe... With all due respect, the listeners know that now. They know that from the review.

What they perhaps don't know, and certainly I would like to ask you just finally to perhaps comment on this, is right now there's a headline across the paper, one next to me just now, saying childbirth is not safe for women in England at the moment until all these actions from Donna Ockenden are put in place. That's what she has said as a midwife and as someone leading the review. What do you say to those women who are pregnant right now? Well, I mean, we have over 600,000 births a year in this country and the vast

majority of them are safe. And the Secretary of State was very clear that a normal birth is a safe birth. We have already acted on many of the recommendations that Donna published in 2020. So, you know, the chief midwifery officer has already instigated the fact that performance on things like ca cesarean sections will be removed. I mean, that's a key factor in Telford. It was. But Donna did say this yesterday. So I'm quoting her from yesterday. So she knows what the review that she already delivered was. She knows what perhaps has already gone on. She's continued looking at this.

And she still said this yesterday. Yes. And so the three key asks she's asked of the Secretary of State in particular, he said he's implementing already. He's already announced the funding, the extra funding on top of the £95 million this week. The funding, which, by the way, Donna also says, Donna Ockenden, is still significantly short of the £200 to £350 million recommended by the Health and Social Care Select Committee. If you put the £95 million which we had in place already and add that to the £127 million announced this week, that does get us to over the £200 million figure. But we're also introducing the Special Health Authority, which will carry on the work from HSIB,

where anyone, a parent, a relative, a staff member, can instigate an investigation if they're concerned about performance of care. And we're also he's already setting up the maternity task force transformation programme, which will look at systemic failures, not just for Telford and Shrewsbury, but across the country, because we absolutely want to make sure that this isn't happening anywhere else. Do you think the NHS is a sexist system? Well, that's an interesting question, Emma, because in my work across women's health and the women's health strategy that we're devising, the failure to listen to women seems to be across the NHS, whether it's young women trying to get diagnosis of endometriosis,

whether it's mums who are worried about their pregnancy or their baby. So what's your, I'm sorry, I have to push you Minister for your time and for ours. Is the NHS a sexist system? I don't think it's a sexist system, but the voice of women is not heard loud enough. And I'm passionate about changing that. Well, your colleague, your colleague, your conservative colleague, Alicia Kern, stood up yesterday and said, I've concluded that the NHS bureaucracy has a systemic problem of sexism. I think it has a systemic problem of not listening to women.

I think that may be slightly different. You know, the NHS is vastly made up of female workers. Yeah, it doesn't mean the system's not that, though. That's why I wanted to ask your view of the system. That's why I specifically asked you that question. Maria Caulfield, thank you very much for your time. The Minister for Primary Care and Patient Safety. I'm sure was an NHS maternity service that failed, failed to investigate, failed to learn, failed to improve and therefore often failed to safeguard mothers and babies at one of the most important times in their lives. I did speak to her,

to Donna Ockenden, just before coming on air and I started by asking her what the key factors were in creating that environment in the maternity services at the hospital that led to such major problems? I think that it's a very complex picture. Staffing did play an issue in what happened at the Shrewsbury and Telford Trust. Equally, there was very definitely a failure to listen to women, a failure to listen to families. And then there were significant flaws in the way that maternity incidents were investigated. If you don't investigate, you don't learn. So I wouldn't want it to be said, oh, it was this or it was that. It was a toxic mix of so many

things. Are all those people gone now? Or do they still operate in the hospital? If I was to go into that hospital within the trust, I should should say within the different hospitals and settings are there different personnel you would need to talk to the trust about that um some members of staff left and went to work in other trusts because they couldn't work in that environment and some will have retired but i think you would need to speak to the Trust about that situation because we had access to a very small number of staff. One of the big issues that we faced was that overall, only 109 staff came forward to talk to us.

In the last few weeks, as we were literally finalising the report, 11 dropped out. So we were left with only 98 staff. But in recent weeks, right through March 2022, current members of staff on the ground were contacting me and my team every which way they could, saying that they still felt unable to speak out, they still had fear of reprisals. So, you know, there remains, to my understanding, a very worrying culture in the trust as we speak in the here and now. And is it right that women are still coming forward with the issues with regards to this trust? So our main cohort of families, although there were some older ones and some more recent ones, our main cohort of

families, women, was from 2000 to 2019. As I said yesterday, there were a number of families that came forward with what appeared to be very serious issues, although, you know, with reports that had been done into their care wanting to be a part of our review we couldn't accept them fully within the review but I have a phrase that my team and I we can't unknow what we know so what we were able to say to those women is we can represent you in the review because we can see from your independent they were high quality, that the themes in your case are very similar to the themes we have seen throughout the whole period of the review. So we officially closed to new cases joining us in July 2020. This means that our review and our report, and I can't underline this enough, it is not a historic review i won't have

that said about the experiences of our families it's not historic um it's up to you know relatively recent times i mean if there's headlines today across the papers using your words that childbirth is not safe for women in england and yet we do know, because you've said those words, just to connect them to what else you say, unless all of the recommendations from your report are taken on. And yet we do know that the majority of people do have their children safely. So how do those two things go together? Okay. So the first thing is if we can not describe our findings as recommendations, recommendations will come and go. They are immediate and essential actions. So they've been put together by my multi-professional team of midwives and expert doctors, and they provide

a roadmap to ensure that we achieve safe care for all. It is absolutely true to say that the majority of women give birth to their children safely across England but what we identified in Shrewsbury with our full consideration of 1,592 cases is that all trusts should be told they must consider all of the IEA's immediate and essential actions in this report, and they must monitor their progress, their achievement against them. And of course, we also were very clear in endorsing many of the findings of the Select Committee report from last summer summer we are very clear that there does need to be a multi-year settlement in terms of funding for our maternity services midwives are important but it's not just midwives it's the whole multi-professional maternity team

including obstetricians anesthetists neonatologists, money spent on what we call neonatal equipment. There is a lot to do. Do you have faith that that funding settlement will be reached by the government? Absolutely, yes. I was delighted to meet the Secretary of State last week and then to see him at the dispatch box in Parliament yesterday. ystod y wythnos diwethaf ac yna i'w gweld yn y ffosg ymgyrch yn y Pyrlawn ystod y dydd, doeddwn i ddim wedi bod yn fwy hynod o ddiolch i'w gweld ei fod yn cynnwys ein penderfyniadau ymwneud â'r pethau bwysig. Ac yna wrth gwrs mae rôl pwysig wedi'i chwarae gan Yr Ymddiriedol Jeremy Hunt, Prif Weinidog y Pwyllgor Cyflawniol, a ddywedodd y cyflwyniad hwn yn ddiweddar

ac nawr mae ganddo wybodaeth mewn gwirionedd iawn o bawb sy'n gysylltiedig â chyfartalwch ymddygiad. rest of this review and now has a really in-depth knowledge of everything associated with maternity safety. You know, he further discussed in Parliament yesterday that these are immediate and essential actions. The issues at the Trust are not unique to the Trust, but what seems to be unique, you tell me otherwise, is that it had become so toxic and so commonplace. Why do you think that happened at that trust? So I think there was, from the very earliest cases, so as I said yesterday, we did see some earlier cases before 2000. And we felt we had a duty that if families had questions and were distressed about what had happened to them in the years preceding 2000 we had a duty to try and find those answers but our main and we did that our main cohort of families from 2000 onwards showed that that was

a trust that simply wasn't listening the mum mum of Olivia, called Julie, spoke yesterday and agreed to be, you know, named as part of my report. Her little girl, Olivia, died after a horrible forceps delivery that went badly wrong in 2002. Four years later, in 2006, her mum was still trying to get her story heard. She went on this morning television programme to say, and she said to me, I just wanted someone to do something. And that never happened. But how does toxic, that's what I'm trying to understand is how does that sort of culture come about? So I think it was a mix of the multi-professional team, this is doctors and midwives believing they knew best. No one challenged their behaviour, so there was a culture of blaming women for what happened to them. You know, if babies were born that didn't survive because they were too small

or the baby's movements had reduced and hadn't been regarded we came across cases where babies had died during long induction of labor processes and a mother very clearly records saying being told well you know you patients you do like to sleep, you know. But where? So I recognise these are individual doctors and individual midwives who will have had those sorts of conversations. Did you find out if that came from the top? Did it come from the CEO, that sort of culture we know best? Or did it come from individual doctors and then it sort of spread as a clique? So I think again it's a complex picture and it's both of those what we said was that there was no leadership at board level there were more than 10

chief executives during the 20 years so they would come in not look over their shoulder at what happened yesterday but decide for the time they were at the trust to forge onwards and of course within 18 months two years they were gone and what happened on their watch was then forgotten or put on a shelf metaphorically speaking the other thing um that staff were very honest about um one member staff used the phrase the republic of maternity they told us that at the royal shrewsbury hospital there was a car park culture and i thought what on earth is that maternity was on one side of the car park the main unit with its A&E and its surgical and medical parts of the acute parts of the hospital non-maternity with the other and someone said you didn't dare cross that car park so I think it's what we've described in our report is putting

together a really complex jigsaw there was lack of leadership from the board down, constant change and churn. There was an overconfidence in the maternity department. They thought they were really good. They were wrong. There was a lack of effective oversight from external bodies there may be more but we've certainly found from 2000 to 2018 eight external bodies and reviews completed of maternity services some gave them a list of things to do and said you know you've got to fix these aspects but didn't actually ever come back and check for that than what they were told to do had been done others mistakenly believed they were ac ystyried yr hyn y ddylai eu gwneud. Roedd gan eraill yn ddibynnol eu bod yn dda. Roedd yna adroddiad CCG 2013.

Felly, os ydym yn meddwl bod, ar ôl 2013, nifer o'n 23 o'n plant a'n mamogiaid o'n arbennig wedi cael perthynas ddifrifol, ond doeddent ddim hyd yn oed wedi'u cyfeirio i mewn y adroddiad. Roedd y CCG yn dweud yn hytrach fod yna nifer hir o gyfraithau mawr, weren't even referred to in that report the the ccg instead said that there was a high number of serious incidents but this was due to you know um either over reporting or diligent reporting and they believed without evidence that um the reason for the number of high and serious incidents was because the trust were just so good um at reporting things that others wouldn't report

but there was no evidence to back that up. So are the watchdogs just when you say CCG for our listeners that's clinical commissioning groups and are the watchdogs fit for purpose for instance the Care Quality Commission those who are meant to be appraising these trusts when there isn't an independent review going on? So that's a really good question. It tookd i'r CWC Cymru Cynhyrchu Cwyllt i ddod i'r ymddygiad i ddod i'r ymddygiad i'r CWC Cymru Cymru i ddod i'r ymddygiad i'r CWC Cymru Cymru Cymru. Roedd y rhan fawr o'n 1592 o gyfranogiadau clinigol rydyn ni'n eu cymryd yn ymwneud â'r hyn a ddigwyddodd cyn y CWC Cymru a ddod i mewn ac yn ddiweddar yn dweud bod y gwasanaeth cymdeithasol a'r ymddygiad i'r ymddygiad i'r ymddygiad yn ddewid. considered had happened before the Care Quality Commission came in and finally said that the trust maternity service was inadequate. There were so many lost opportunities.

So it's not fit for purpose, the Care Quality Commission, is what you've just said? What I would say is in this instance, they took far too long to say that there were significant problems in this maternity service. That's a very polite way of saying they didn't do their job. In the case of this trust, they failed to realise, report that there were very, very significant issues and significant issues of harm. In 2015... But what hope have we got, if I may, I'm sorry to cut across, but what hope have we got if the bodies that we hope

will capture this sort of poor care, to call it that? I mean, it's horrendous in so many of the incidences that you've written about and found, that they don't catch it. What hope have we got to have that trust um i i think you're absolutely right the the population of shropshire the women and families of shropshire were badly let down by those externally who should have scrutinized um what was going on in maternity services and internally by the culture that had developed where they felt they knew it all and they were actually really rather good which clearly wasn't

true you're absolutely right do you think this can happen again I think the positive issue that has come out of this review the bravery of the women and families speaking out is that oversight attention um towards maternity services has never been um you know maternity has never been more high profile um and i think that that is a very good thing. It's at the, quite rightly, it's at the top of everyone's mind. It's at the top of everyone's agenda. I think that we're now in a situation where women will be able to speak out and be heard. And that so so important um so i am confident that change will occur of course it shouldn't have taken the terrible harm and distress and damage to so many shropshire families for this to have happened how has it been personally for you writing this report? Oh, well.

So one of the things that we did do to keep our team members safe was to set up a supervision and debriefing service. And as the chair of the review, I guess the front of house, if you like, meeting hundreds and hundreds of Shrewsbury and Shropshire families face-to-face, I did make sure that I used that. It would have been unprofessional of me because there is only, if I hadn't, because there's only so much load you can carry on your shoulders. Some of the stories that I heard face-to-face, the distress,

the grief and the anger was very profound. But despite, you know, using that professional debriefing service, there were nights when I went back to my hotel room, perhaps I'd met five families that day, I would sit in my bed and I would cry. Because to sit with a family, perhaps after the death of a young mother, where you meet the young woman's partner, her brother sister her mum you know a group of perhaps five people who come to tell you about the impact to their family of losing um you know a young woman i mean we all say we've just had mother's day and we all talk about the central role that women play in families and communities and when you lose that person and it's your daughter it's someone's wife

it's someone's mum and you hear the impact on the children who are now without their mummy for the rest of their days I mean it just as one human being to another sometimes to go to my room and cry was the only thing I could do and And then I would pick myself up and say, okay, onwards and upwards, you have work to do. You have a team to lead. And we must get to the place where we publish this report. And I feel on behalf of our families that yesterday was a good day.

It was a huge achievement. But it was an achievement for so many women and families who have been silenced for so long and it must be very strange for you as a midwife to to look at your your your world like this the world that you have worked in and see so much wrong with it even if yesterday was a good day absolutely i mean i've been in and around maternity services in various roles clinical midwife head of midwifery divisional director clinical director i've done all kinds of roles and my focus every single day of my career regardless of my role um has been to provide safe care for women. I think that it's important to say that the vast majority of my amazing colleagues across the NHS in my team,

all of them go in every day to do that. But this is an example where that system failed and it failed hugely and it's left lifelong consequences for a whole community across generations. Yes. And if I may, if you were having a baby soon, would you go and give birth in a hospital under that trust right now? So what I would say to women is that there are the staff on the ground at the shrewsbury and telford hospital NHS trust we've spoken to enough of them i know that they are giving of their very best um i know that if women have concerns they must now speak out they mustn't hold it back they

mustn't sit there thinking oh well doctor or midwife knows best. They must, must question if they are unhappy. But that's a really big change for patients, isn't it? Just to say on this point, because sometimes you want to just go in as a patient and be looked after. And now you're talking about, you know, going against doctors, you know, not necessarily going against against, but just saying when you don't feel something is right. And that balance is very hard to strike. across England and we owe it to the women who have and families I can I just need to stress you know the role of husbands and partners in this as well because they have they've also suffered hugely um from what has happened you know within their families and they've really I've had so many fathers sit with me and just cry over what has happened um but, I think that with maternity services now being right at the top of the health service agenda,

women should feel confident that they will be listened to and that they should speak out. Donna Ockenden, who led that review and that report, which was published yesterday, she put that together. Responding to the publication of that report, the chief executive of the shrewsbury and telford hospital nhs trust has said it was deeply distressing and that they offer their wholehearted apologies for the pain and distress caused by their failings as a trust and that they're continuing

to make improvements and we've spoken a few times this morning about the the care quality commission the cqc the chief inspector Hospitals has said, Ted Baker, as part of our inspection in 2016, we reviewed inspection investigation reports relating to babies who had died since 2014, looking at what action had been taken to ensure learning was shared and safety improvements made. As a result of that inspection, we downgraded maternity services at the Princess Royal Hospital run by the Trust, the Andrew Shrewsbury and Telford Trust, to requires improvement. It's clear now, however, that while our report highlighted that more work was needed to fully embed a safety and learning culture in the service, the inspection did not uncover the full extent of the problems at this service.

And over time, we've strengthened and improved the way we inspect maternity services. And when we returned to the Trust in 2018, we took enforcement action to protect women using its maternity services and when we returned to the trust in 2018 we took enforcement action to protect women using its maternity services rated the trust inadequate and placed it into special measures well at the heart of all of this is the relationship of course between doctors and midwives those who are senior especially let's talk now to the consultant obstetrician dr joe mountfield who's the vice president of the royal college of obstetricians and gynecologists and professor sue down who's a midwife and Professor of Midwifery Studies at the University of Central Lancashire. Dr Mountfield good morning. Morning. Thank you for joining us. A message that's just come in saying as a midwife an anonymous midwife saying the doctors have the power

our voices are not heard if something's not going the way that we think it should be. What do you make of that? Well, sadly, it is a message that we hear and what we're doing within our college is working very closely with the RCM to speak as one voice because that's absolutely not what we want. We have absolutely as a multi-professional team to work together, respecting each other's profession, listening to the women who are talking to us, listening to the opinions of the midwives and the other team members who are around us so that we can use all of that information to give women the best information that they can have so that they can make informed choices about their care. So I think in many units that there is not a culture of the doctors have all the power

and the midwives are not able to speak up. It certainly is not like that in my own unit and in many other units across the country. And I really think that is one of the things that we have to tackle is the relationship. But this must have happened. That's the point, right? Some of this has gone wrong. And's the point, right? Some of

this has gone wrong. And there's an arrogance there, not from you, I meant there's a concern about arrogance and not being able to speak to it. And there's a big concern about women not being heard. We've heard, let me just bring in Professor Sue down. We've heard today about the removal of targets to have natural births. Do you think women are going to get the right outcome with the health setting and some of the lessons perhaps being learned from this? Yeah, I think I should say there never were targets for a natural birth.

There were targets above which hospitals were not paid if their caesarean sections were too high. And the government has now moved to a much better measure, which is actually a measure, something called the Robson Criteria, which carefully um measures cesarean sections by type but by the kind of the way in which the woman comes into labor and birth and by her preferences which are really important i think i would say the great thing about the ockenden report is this emphasis on safe and compassionate care and i think if we

truly listen to women in the way that the the ockenden report suggests then between us all obstetricians, midwives, women, crucially and centrally, we will actually be able to generate a system where women are able to have the kind of labour and birth that they would like to have and where if things don't go the way they want to go, they're able to have an alternative

which creates a positive and safe experience for them. And that, I think, is what we're all working towards, really. Is that actually how it can be on the ground now? I've got so many messages saying the opposite, Sue. It can be that way. I mean, whether it is. But, you know, it sounds like it's not in a lot of places. So what do you say to that?

In a lot of places, you're right, it's not. And what we need to be working together, I think, is trying to find out both learning from where these things have gone wrong, and that is the critical thing. We cannot turn back time, and we have to acknowledge the suffering and the distress that's been caused in many places and to many women and partners and birthing people but what we can now do is look at where it is going right because there are places where it is going right and say okay what are those places doing that we can really learn from to go forward

and obviously the immediate actions that have been suggested are part of that but another part of that is this business of trying to create cultures where where trusts prioritize staff spending time with women but what do you do let me bring joe back in at this point what do you do we heard about the republic of maternity right and this whole clique that had grown up this whole culture what do you do if you're in that right now and you've got a doctor that just won't listen then you need to escalate that and there are mechanisms within the nhs to be able to escalate that within the organization not least there are at board level maternity safety champions that you can contact if you have some concerns but there are also um the guardians of safe working

where you can go and talk to them confidentially about concerns. And you can certainly contact the Royal Colleges and also raise concerns there. So there are a myriad of different mechanisms that you can raise those concerns. And it's our job as leaders to help support those organisations to improve and to ensure that their culture changes from one of this, you know, isolated arrogance, as you've put it, to a culture where we are a supportive team that has time. And I think this is about people having time together. So training is actually really important. If I may, another message that's come in saying, do I think I can speak out? It's from a midwife I have, but repeatedly not listened to.

I'm so sorry of course to the families concerned in this there is that concern I suppose if I just with the limited time I've got Jo to put this back to you because you are the vice president of the Royal College of Obstetricians and Gynaecologists what about if you're a woman in this situation and you don't know what you need but you sort of don't feel this is going right or going well what would you say as advice? So I would certainly say if you've talked to your midwife and you really don't feel this is going right or going well, what would you say as advice? So I would certainly say if you've talked to your midwife and you really don't feel you're getting the answers that you need,

there are other members of the team that you can talk to and ask to speak to. You can always ask to go and speak to an obstetrician. And if you really are not... If you're in labour and they say, listen, we've got no one else here, what are you going to do? So in labour, I would suggest that you need your partner as advocate then to actually talk to, because there are, even within labour, there are other people around where you can say, please, could I have somebody else to come and have this discussion with me?

A senior midwife, an obstetrician, a consultant, there will always be somebody else that you can have that. But in labour, we hope we don't get to the situation of women feeling underconfident and not happy with the information that they're getting in labour. That's beholden on us as professionals to help support women so that they do not find themselves in a situation in labour where they're feeling unsupported, not confident, because that will not give them the best outcome for either themselves or their baby. Sue, a message again from another midwife says, our own C-section intervention rates are through the roof, contrary to reports of a focus on a normal birth. This is all introducing its own risks and women are poorly counselled. Final word from you, Sue, very briefly. Yeah, I agree. There should be a balance between the two. Women should have, women and birthing people, the kind of labour and birth they want and need, and that's both normal or physiological or a caesarean section, depending on the circumstance. The circumstance is what matters and what the women want and need is what matters.

And I suppose those voices being heard, the women's voices at the heart of all of this. Well, we always aim to do that here on Women's Hour. Thank you very much to everybody who took part in today's special programme, focusing on this maternity scandal, the greatest maternity scandal in the NHS's history. We're just listening there to Dr. Jo Mountfield and Professor Sue Down. And thank you very much for many of your messages and your company as always this morning. We'll be back with you tomorrow at 10. That's all for today's Woman's Hour. Thank you so much for your time. Join us again for the next one. Hi. Yeah, you. Hello. Hi. Don't go go away i've got a quick couple of questions for you if you don't

mind so how much do you think you really know about the menstrual cycle beyond the period bit did you know par exemplar that the hormone oestrogen makes you smell better or that your hormones change the way your brain works hour by hour and that you could even biohack them to maybe, I don't know, bag a job or run a PB. No, that's not surprising, you're not alone there. The mysterious workings of the womb have been a dark secret for centuries. The ancient Greeks thought the womb was a mischievous moving creature that wreaked havoc on the body. And the Victorians, well, they thought that if you examined a woman's vagina, she would

devour you in a mad fit of sexual rage. As you can see, we are really on the back foot here. All of us. I'm India Rackson. And when I found out about the amazing things that happen in our wombs and brains through the cycle, my mind was so blown that we got to work making this podcast. 28-ish Days Later for BBC Radio 4. 28 episodes, each charting every day of the very approximate 28-day cycle.

It looks at the science of our bodies and the way that we've been treated through history and discovers how understanding our cycle can change our lives. Fancy striding back into your powerful menstruating self? Me too. And you can listen to 28-ish Days Later now on BBC Sounds. I'm Sarah Trelevan, and for over a year, I've been working on one of the most complex stories I've ever covered. There was somebody out there who was faking pregnancies.

I started, like, warning everybody. Every doula that I know. It was fake. No pregnancy. And the deeper I dig, the more questions I unearth. How long has she been doing this? What does she have to gain from this? From CBC and the BBC World Service, The Con, Caitlin's Baby. It's a long story, settle in. Available now.