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Tory ministers were “asleep at the wheel”, in relation to maternity safety and “didn’t put the effort into” improving care in the sector, a senior midwife has said.
Donna Ockenden, chair of the inquiry into maternity failings in Nottingham, also backed calls for NHS managers to be professionally regulated, amid failings to address safety concerns.
The inquiry was launched after The Independent exposed more than 60 cases of harm by Nottingham University Hospital Foundation Trust.
In an update to the investigation, given on Wednesday, Ms Ockenden said the inquiry is looking at more than 1,941 cases of potential harm and death to babies and mothers between 2012 and 2025.
Ms Ockenden also led an inquiry into maternity failings at Shrewsbury Hospital which found more than 200 babies and nine mothers died due to poor maternity care between 2000 and 2019.
Commenting on the Conservative government’s role in maternity failings, Ms Ockenden said: “We published the Shrewsbury and Telford review March 2022, with a number of immediately essential actions.
“I was grateful for the time that Jeremy Hunt and Sajid Javid gave to me in the run up to that review, and the fact that the government and Sajid Javid fully endorsed all of the immediate essential action and he said they would be put in place swiftly.
“Fast forward another two years, and they haven't been put in place swiftly at all. Some progress has been made, but my phrase falling asleep at the wheel is that the government were handed a blueprint, a roadmap for safe maternity care in England, and they simply didn't put the effort into it that they could have and should have. They knew what they needed to do.”
On the regulation of NHS managers, she said “there are some concerns managers right up to board level who are not regulated who can move from trust to trust, so I think we will see greater calls for the regulation of managers...I would support that.
Ms Ockenden also suggested the review, due to be published next September, will also comment on the role of the Care Quality Commission, Nursing and Midwifery Council and General Medical Council, as families have aired concerns over how the regulators have treated them.
“Families have experienced significant delays in consideration of what happened to them, significant disappointment and they’re not yet satisfied that those three regulators are regulating in the way they should. Families have made their views very clear to all three organisations,” Ms Ockenden said.
The Nottingham inquiry chair said further injection funding would “absolutely” be needed for maternity services under the current government. She pointed to the billions spent on maternity negligence claims each year, which could be funnelled into frontline maternity care.
Nottingham Police are currently carrying out a criminal investigation into the maternity failings at NUH.
Speaking with The Independent Jack Hawkins, whose daughter Harriet, died due to negligence by NUH said: “When we say accountability is important, it’s not because we’re just angry. We are and we’re frustrated, but we’re also aware that lots of things have happened that haven’t made a massive difference, the lack of accountability, the same people who managed, ran and advocated for unsafe services, and who then took part in attempts to frankly, diminish and destabilized families, they are still there.
He said there continued to be “malevolent” staff at the trust who “need to be found and have something that changes their behaviour or be dismissed and taken for a criminal proceeding.”
Harriet died before her birth at Nottingham City Hospital on 17 April 2016, as a result of a series of failings by the hospital. An independent investigation was pursued by the couple after the trust claimed the death was the result of an infection and “no obvious fault” on its part.
However, the investigation concluded in 2018 that it was “almost certainly preventable” and identified at least 13 mistakes in her care.
In 2021 Jack and his wife Sarah Hawkins won a clinical negligence claim against the trust who were forced to pay out £2.8 million.
Nottinghamshire University Hospitals chief executive Anthony May, told The Independent that trust clinicians faced a difficult situation with such high levels of scrutiny but he did not see outright resistance to change from staff.
When asked whether NHS managers should be held accountable through a professional regulator Mr May said: “If in the fullness of time, regulation is applied to management in the NHS, then I’m sure it will be done sensitively and appropriately. But of course, in the end, it will be a mechanism for the public to hold people like me to account in truth, I already feel accountable, but if there are regulation standards against which we managers will be held accountable in a more formal way, I’m sure that most managers in the health service that I know would welcome.”
As part of its update to the report, NUH announced a new family liaison service for women and families whose lives have been affected by maternity failings at the trust.
In a speech on Wednesday on NHS reforms, health secretary Wes Streeting concerns over maternity care keep him awake at night.
He said: “When it comes to the crisis in our maternity services across the country, it is one of the biggest issues that keeps me awake at night worrying about the quality of care being delivered today at the risk of disaster greeting women in labour tomorrow.
“I think that what we have seen, in the case of specific trusts, are problems and risk factors that exist right across maternity services across the country.
“And we’re keen to make sure that when it comes to the work that Donna Ockenden has already done, we make sure that those lessons are applied, not just in the case of those specific trusts, actually right across the country.
“We are determined to get this right.”
