Reading the recent news coverage of care failings within the Shrewsbury and Telford Hospitals NHS Trust will have been very painful for bereaved parents across the UK and especially for those who have been affected directly.

We commented on the Ockenden report when it was published, but I wanted to share some further reflections on what needs to change in order for such tragically poor practice to be consigned to history.

The Ockenden review was ordered in 2017 by the then Health Secretary, Jeremy Hunt, after the families of two babies, Kate Stanton-Davies and Pippa Griffiths, who died under the trust’s care, raised concerns about their cases and 21 others.

It is their stories, and the stories of all the other families that have been affected, that underline the devastation of the families at the heart of this tragedy. We have been working closely with Donna Ockenden and her team since December 2019, providing support for those families involved in the investigation as part of their Listening Ear service. We will continue to work with families throughout the remainder of the investigation and beyond.

But what can we do to make sure that nobody else has to go through these heart-breaking experiences?  

Maternity services across the UK must take urgent action to improve safety for mothers and babies, however there is no one single action that can achieve this, rather, several very important actions supported by a change in culture.

Firstly, it is essential that the voice of bereaved parents is at the heart of any investigations related to care.  Parents have the greatest stake, and a unique insight, in understanding what happened when something goes wrong, and why their baby died; they want learning from investigations to result in swift and effective change so that nobody else has to go through what they have been through.

Secondly, we need to be proactive in identifying Trusts where there is a risk of avoidable deaths, rather than reacting once tragedies have occurred.  What is urgently needed is a system that identifies Trusts who are experiencing problems early, coupled with a system of support to prevent errors that lead to deaths or injuries from happening.

Blame will not bring back those babies who have so tragically died, or heal the pain felt so deeply by their mothers, fathers, and families. If we really want to stop this happening again we need to work with Trusts to help them improve, rather than having a putative system that incentivises cover-up and failure.

A report such as this one is a moment for us all to stop and reflect what more needs to be done.  At Sands, reducing the number of babies dying before, during and shortly after birth is an absolute priority, and improving maternity safety is a key part of this.  Our work in relation to maternity safety takes many different forms, but always includes the voice and perspective of parents.

Sands is a member of the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries) collaboration and this week I attended a virtual Conference to launch the MBRRACE-UK 6th annual report, for which I wrote the foreword.  The data collected and presented by MBRRACE-UK in their annual reports and confidential enquiries improves understanding of where and why babies die.  Using this information effectively is essential.

Sands is also a part of the collaboration which developed the Perinatal Mortality Review Tool to ensure that every baby's death is reviewed.  The inclusion of parents must be a central part of these reviews. Learning from them is an integral part of improving safety in care and in preventing tragedies such as Shrewsbury and Telford.

Alongside this work, Sands continues to actively campaign for improvements in maternity safety, seeking urgent action to address problems in failing Trusts and Health Boards and also calling for the fully integrated maternity safety system described earlier that identifies problems early and supports NHS Trusts and Health Boards to improve. As a part of this we are supporting the ongoing Maternity Safety Enquiry by the Health Select Committee, and also engage in discussion with NHS England maternity safety leads.

I truly believe we are at the heart of the drive to improve safety in maternity care and to save babies' lives – working with key influencers and decision-makers who know that the parents' voice is integral to understanding how to improve care.

Clea Harmer

Chief Executive, Sands