Maternity inquiry chair says she has learnt lessons from past reviews

When it comes to reviewing maternity services, there is one person who often appears to get called on to lead them - Donna Ockenden.

The independent senior midwife previously reviewed failings at Shrewsbury and Telford Hospital NHS Trust and is leading ones into Nottingham, Leeds and Sussex - with the Nottingham report due to be published on Wednesday.

Four years on from her devastating report into the failings in Shropshire, Ockenden still works with some of the families in the county along with its hospital bosses.

She is hopeful that things are finally moving "in the right direction" at the Shrewsbury and Telford Hospital (SaTH) NHS Trust, ahead of the publishing of her Nottingham review.

Her report in 2022 into the failings in Shropshire found that more than 200 babies and nine mothers could have survived with better care.

Ninety four children suffered life-changing injuries - among them, Adam Cheshire, now 15.

He suffered a brain injury, is hearing and visually impaired, has profound learning difficulties and his needs are so great that he now lives in residential care with a team of people looking after him.

His mother, Reverend Charlotte Cheshire said, "When I chose to have a child I had no idea that I was going to be entering a scenario like this, where I would be doing my level best, supported by an army of professionals, to raise a profoundly harmed child.

"I'll do anything for him that I can but it's not the life we should have been living. And it could have been avoided."

With a son so severely disabled due to failings at the Royal Shrewsbury Hospital, she could be forgiven for walking away from bosses.

But Cheshire is among families pushing them for proof of change, attending "family board" meetings with the trust and Ockenden.

"It's four years too late, but they're listening, and that's positive," the reverend said.

She is referring to the fact that Ockenden had to return to Shropshire in 2024, two years after her final report.

Ockenden said she had to come back "because families raised concerns that they simply hadn't been spoken with or listened to by the trust.

"So there's been a lot of catching up to do but we are now starting to see real significant progress in that relationship between families and trust," she added.

Cheshire added: "There is a family board that is working together with the trust, saying, 'this is what we need to see'.

"We need to not just see headlines telling us you've improved, we need you to demonstrate it, and this is what we need you to do. And the hospital trust is listening."

A trust spokesperson said they now had a consultant obstetrician in the delivery suite at the Princess Royal Hospital in Telford at all times.

Ockenden said an auditor was also scrutinising evidence of other improvements Shropshire hospital officials said they have made.

"What has been evidenced so far is that we recommended an independent auditor who had done some brilliant work alongside the review in Nottingham.

"My understanding is that, within the next six weeks, families will be able to hear her findings. And as far as I'm aware the findings are pretty positive."

A film of Cheshire's story will be shown to new staff in Shropshire in the future.

In an excerpt she said: "I might be next in your clinic, expected to trust you, a clinician who did not harm me or my child. But will it be easy for me to trust you? Never."

The story of another harmed family has already been shown to staff in training sessions.

Ockenden was cautiously optimistic about the future in the county.

"I'll stay for as long as I'm needed and when I'm no longer needed I won't be there," she said.

"So let's say I'm hopeful that my time in Shropshire is coming to a close. But I don't know that for certain yet."

Ockenden has been returning to Shropshire as well as working on the Nottingham maternity review.

She said she would also remain in Nottingham post-review, as a result of what she learnt in Shropshire "to oversee the progress that the trust is making" in improving.

"I think that's really positive. It shows learning from what didn't happen in Shrewsbury and Telford and I think it gives families confidence," she said.

Cheshire said her thoughts were with Nottingham families, saying "their stories matter".

"I hope they will take care of themselves, and be gentle with themselves because this is a difficult time," she said.

But she felt strongly that a statutory public inquiry into maternity care across the country was now crucial.

"I think we're at the point where the level of harm is so catastrophic, we need something where evidence is required," she added. "To make sure we actually get to the bottom of these issues and solve them."

The Department of Health has been approached for a response over the call for an inquiry.

The chief executive of SaTH, Jo Williams, said they knew Wednesday's report on Nottingham would "bring back painful memories" for families they "let down" in Shropshire.

"We will reflect carefully on the report, ensuring that its findings and the voices within it guide us in the care we provide," she added.

"Listening to women and families, working together, and acting on feedback are essential to delivering safe and compassionate maternity services.

We remain focused on ensuring lasting improvements in the care we provide, while making sure that the experiences highlighted through the Ockenden Review are never forgotten."

Follow BBC Shropshire on BBC Sounds, Facebook, X and Instagram.