Independent report - Ockenden review into maternity services at Nottingham University Hospitals NHS Trust

FINAL REPORT: 

'This independent review of maternity services at the Nottingham University Hospitals NHS Trust (NUH) considered the quality of care relating to newborn, infant and maternal harm at the trust.

This report covers the findings, conclusions and essential actions of this independent review of maternity services.

Based on a review of over 2,500 family cases that formed part of this investigation, the final report outlines:

• local actions for learning that staff at the trust must do
• system-wide learnings
• immediate and essential actions to improve maternity and neonatal care

The Independent Maternity Review (known as the Ockenden review) was led by Donna Ockenden and involved a multi-professional team of more than 160 reviewers. The review team held individual meetings with over 500 families, and more than 830 current and former staff at NUH engaged with the review.'

https://assets.publishing.service.gov.uk/media/6a3bb59c4c7605ab567238ec/ockenden-report-review-of-maternity-services-nottingham-university-hospitals-nhs-trust-e-lay.pdf

https://www.ockendenmaternityreview.org.uk/

individual

|
INTERPERSONAL : SCIENCES             

humanistic ------------------------------- mechanistic

SOCIOLOGY : POLITICAL   

|

group

listening	Communication Processes  Health Systems
mothers families experience	LISTENING staffing funding

Previously: 'maternity' : 'risk' : 'safety' : 'compassion'

"Train midwives as nurses" - Ockenden

Re. Ockenden Report

Catching up on the newspapers, I noticed in the Times reporting of Ockenden calling for midwives to train as nurses first. Provoking debate about nurse education.

Within maternity services there are problems with continuity of care and skills in dealing with complex cases:

'Maternal Deaths 

60. The Review examined 27 maternal deaths that occurred between 2006-2024. Five cases fell outside of the Terms of Reference of the Review. Of the 22 remaining cases, reviewers identified failures in care that may have or substantially impacted on the outcome in six deaths. 

61. The profile of maternal deaths at NUH over this period broadly aligned with the known demographics and causes as identified by MBRRACE. 11 of the deaths occurred to women living in the most deprived areas of the city and 14 occurred amongst women who were not white British.

62. The common failures reviewers identified that might prevent future maternal deaths included: listening to women and families and acting promptly on concerns; continuity of care particularly for those with additional social/medical complexities; robust clinical governance to ensure timely information sharing across organisations and prompt access to imaging for women presenting with concerning neurological symptoms.' xiv

AI Overview (Ecosia) suggests that although direct entry to midwifery has always been possible(?), the English National Board created the pathway some 39 years ago.

The Ockenden Report describes how in combination health systems, culture, leadership and training can contribute to compassion fatigue (p.313).

When you look at Hodges' model and our languages, a great many challenges for curricula, training and education programmes can be found. The most powerful of what can be progressive, or threats are invariably mechanistic:

• shorten
• bypass
• shortcut
• cutting corners
• short-circuit

Nursing must always move forward, continuous professional development is built on this principle. In the late 70s and 1980s post-registered qualifications were held in high esteem. Especially midwifery, paediatrics, health visiting, emergency and intensive care. 

Clearly, decision and policymakers can underestimate the value of basic nurse training. Having an idea since childhood is brilliant, but at interview saying you're compassionate and want to make a difference will soon be tested. Sometimes as a student rather bluntly, as with a first placement in forensic nursing. I wonder how many students have been lost there? I'm sure the majority will cope, manage, enjoy and prosper, but I've seen the student peers who miss these cohort members on subsequent learning experiences. What preparation is employed?

Basic nurse training, is just that. Demonstrating competence in communication, awareness of basic needs and how these are expressed behaviourally. What interpersonal skills and knowledge are needed. As highlighted before, the director of nurse education worried about those of us who worked as nursing assistants risked being trained in poor care. Not recognising 'bad practice', a 'poor attitude', not using observation and most important of all listening: to what is said and unsaid. When I started I remember thinking about not responding - as individually programmed to do so, through a reflex action. That was a worry back then. 

While the news in the Ockenden Report is bleak. The depth of the report (for me) is manifest in identification of not only socioeconomic factors, but sociotechnical too (with five mentions) and the critical interplay of seeing (and hearing!) the individual amid the collective:

'2. Fetal monitoring

Rather than reflecting simple failures of individual interpretation, growing evidence suggests that intrapartum fetal monitoring is best understood as a complex sociotechnical practice, shaped by system design, workload, team dynamics, guideline variability and organisational culture.119 Continuous CTG itself has well-recognised limitations, including poor specificity for predicting long-term neonatal outcomes and substantial inter- and intra-observer variation in interpretation.5 Reviews of intrapartum care are therefore unavoidably influenced by retrospective bias, with greater apparent clarity afforded by knowledge of the outcome than was available to clinicians at the time. 

However, despite this, a sociotechnical understanding does not negate the importance of examining individual cases in which intrapartum monitoring was demonstrably substandard. National inquiries and confidential reviews repeatedly describe cases involving sustained failure to recognise pathological fetal heart-rate patterns, delayed escalation despite repeated triggers, and missed opportunities for timely intervention. 2,3,120,121 These cases cannot be explained solely by the inherent limitations of CTG or by hindsight bias.' p.143.

It is quite shocking to hear this conclusion: the need to train as a nurse first. Counterarguments: where is the evidence(?!) - have followed. But then if you undervalue and miss the fundamentals (see Hodges' model!) then individuals, families, communities, students, practitioners, services and systems suffer.

Previously: 'maternity' : 'report' : 'safety'

Invitation to participate in Round 2 of the global survey of maternal and newborn health providers during COVID-19

ENGLISH

Subject line: ...

Dear colleague

Thank you for participating in the first round of the research study on the response to COVID-19 among maternal and newborn health providers. Your responses and those of nearly 2,000 others have contributed to a better understanding of how maternal and newborn care is affected by the pandemic. We summarised and published the first findings here.

As the COVID-19 pandemic evolves, we need to keep tracking and responding to the needs of health professionals, and women and their families. At this time, we would like to invite you to answer the second round of this survey available here in 11 languages. It takes 15 to 30 minutes to complete.

Additionally, we would appreciate it if you could distribute this email and survey link to your colleagues (in your facility, community, country, professional association etc.), who are welcome to respond to this survey, whether they participated in the previous round or not.

We thank you for the care you provide to women, babies and their families in these difficult times. Please feel free to get in touch with the research team at the Institute of Tropical Medicine in Antwerp Belgium should you have any questions or suggestions. This study was approved by an ethics committee, and is led by Dr. Lenka Benova (lbenova AT itg.be).

With our very best wishes and many thanks

The COVID-19 maternity survey team


FRENCH

Sujet: Invitation à participer au deuxième volet de l'étude sur la réponse au COVID-19 au sein des prestataires de soins de santé maternels et néonataux.

Chères et chers collègues,

J’espère que vous vous portez bien. Nous vous remercions chaleureusement pour votre participation dans le premier volet de l'étude sur la réponse au COVID-19 au sein des prestataires de soins de santé maternels et néonataux. Vos réponses et celles de près de 2,000 autres prestataires ont contribué à une meilleure compréhension de la façon dont les soins maternels et néonatals sont affectés par la pandémie. Nous avons résumé et publié les résultats préliminaires ici.

À mesure que la pandémie de COVID-19 évolue, nous devons continuer à suivre et répondre aux besoins des prestataires de santé, des femmes et de leurs familles. Pour le moment, nous vous invitons à répondre au deuxième volet de cette enquête disponible en 11 langues ici. L’enquête en ligne prend environ 15 à 30 minutes à compléter.

De plus, nous vous remercions de bien vouloir distribuer ce message, ainsi que le lien du questionnaire, à vos collègues (dans votre hôpital, communauté, pays, association de professionnels etc.), qui sont invités à répondre à ce questionnaire, qu'ils aient participé ou non au volet précédent.

Nous vous remercions pour les soins que vous apportez aux femmes, aux nouveaux-nés et leurs familles dans ces moments difficiles.

Vous pouvez à tout moment prendre contact avec l’équipe de recherche de l’Institut de Médecine Tropicale d’Anvers (Belgique) si vous deviez avoir des questions ou des suggestions à propos de l’enquête. Cette étude a été approuvée par un comité d’éthique et est dirigée par Dr. Lenka Benova (lbenova AT itg.be).

Nous vous remercions d’avance pour votre aide précieuse,

L’équipe d’enquête COVID-19 -maternité.


PORTUGUESE

Subject line: Convite para participar da segunda rodada da pesquisa global com profissionais de saúde materna e neonatal durante o COVID-19

Caro colega

Obrigado pela sua participação na primeira ronda da pesquisa sobre a resposta ao COVID-19 entre os profissionais de saúde materna e neonatal. As suas respostas e as de outras quase 2.000 pessoas contribuíram para uma melhor compreensão de como os cuidados maternos e de recém-nascidos estão sendo afectados pela pandemia. Resumimos e publicamos os primeiros resultados aqui.

À medida que a pandemia do COVID-19 evolui, precisamos de manter o acompanhamento da situação e responder às necessidades dos profissionais de saúde e das mulheres e suas famílias. Neste momento, gostaríamos de convidá-lo para participar na segunda ronda desta pesquisa disponível aqui em 11 idiomas. Demora entre 15 à 30 minutos para responder o questionário.

A equipa da pesquisa agradeceria o seu apoio em distribuir este e-mail e o link da pesquisa para seus colegas (na sua Unidade de Saúde, comunidade, País, Associação Profissional etc.), que possam responder a esta pesquisa, independentemente de terem participado da ronda anterior ou não.

Agradecemos pelos cuidados de saúde prestado às mulheres, bebês e suas famílias nestes tempos difíceis. Caso tenha alguma dúvida ou sugestão, sinta-se à vontade para entrar em contacto com a equipe da pesquisa liderado pelo Instituto de Medicina Tropical em Antuérpia na Bélgica. Este estudo foi aprovado por um comitê de ética e é liderado pela Dra. Lenka Benova (lbenova AT itg.be).
Com os nossos melhores votos e muito obrigado

A equipe de pesquisa de COVID-19 e maternidade


SPANISH

Asunto: Invitación a participar en la segunda ronda de la encuesta mundial de proveedores de salud materna y neonatal durante COVID-19

Querido(a) colega

Les agradecemos su participación en la primera ronda del estudio de investigación sobre la respuesta a COVID-19 entre los proveedores de salud materna y neonatal. Sus respuestas y las de 2000 personas más han contribuido a una mejor comprensión de cómo la pandemia afecta la atención materna y neonatal. Hemos resumido y publicado los siguientes primeros hallazgos.

A medida que evoluciona la pandemia de COVID-19, debemos seguir respondiendo a las necesidades de los profesionales de la salud, las mujeres y sus familias. En este momento, nos gustaría invitarle a responder a la segunda ronda de esta encuesta, disponible aquí en 11 idiomas. Estimamos que necesitará de 15 a 30 minutos para completar la encuesta.

Además, le agradeceríamos que pudiera distribuir este correo electrónico y el enlace de la encuesta a sus colegas (en sus unidades de servicio, comunidad, país, asociación profesional, etc.), a quienes pudiesen responder a esta encuesta, ya sea que hayan participado en la ronda anterior o no.

Agradecemos la atención que brindan a las mujeres, los bebés y sus familias en estos tiempos difíciles. Si tiene alguna pregunta o sugerencia, no dude en ponerse en contacto con el equipo de investigación del Instituto de Medicina Tropical de Amberes, Bélgica.

Este estudio dirigido por la Dra. Lenka Benova (lbenova AT itg.be) ha sido aprobado por un Comité de Etica.

Muchas gracias,

El equipo de encuesta de maternidad COVID-19

Person-centred care and semantic inflation

Time laughs at us, with us and has the last laugh. If you are ever complacent and by virtue of your years you venture to think to yourself:

Well we've been working on this now for 20-30 years look at the progress we've made. ...

Time is always there to remind you:
Hey, just who are you trying to fool?
You are a lifelong learner!

The number of personnel and services that describe themselves as person-centred is an ongoing theme of so many CVs, policies, SLAs, commissioning and consultant's presentations and lectures. ...

Whether in a ward, service, or organisation's philosophy, person-centred is a term that is being diluted to the extent that semantic inflation devalues what is supposed to be the main currency? Or are we admitting that this is the cost of the political games that people play? Whatever your view, there are insights of progress won, but also reminders on how much remains to be done.

Health and social care being multicontextual demands the existence of multiple currencies. One additional currency begs that we compare A, B, C with the evidence base.

If this is the crucible of our person-centred times then what is burning?

• Nursing ethics?
• Nursing education?
• Idealistic aspiration? (Yes, we will get there!)
• New Age incense?
• Policy initiatives?
• Funding allocations?
• Nursing activism (Or, are there any balls in the house)?
• Service infrastructures?

Although the media temperature is rising here in the UK, as health, itself economically recumbent is moved to ICU being so politicised; the Francis Report provides evidence of a dire lack of person-centred care. Recalling my basic nurse training: what can be more person-centred than ensuring that a patient has the necessary fluids and diet?

For women who suffer a miscarriage - where should they be nursed as debated in today's Guardian newspaper? What is person-centred care in maternity and gynaecology services?

In-patient provision and transitions from child-youth-adult provide other opportunities and major challenges for health and social care to demonstrate their person-centredness.

There are so many ways to be person-centred, so many levels, some may even be contradictory(?).


I wonder how many of those people highlighted in the Francis Report also had a form of dementia - whether diagnosed or not? Personhood and the need to acknowledge and sustain the person are not new.

Even if a service is person-centred in terms of the environment, meal choices, therapeutic options, belongings, personal space, proximity to home and relatives ... the crux at the center is the attitude of staff, and their having the time and space:

"to be"

person-centred

Additional links:

Mumsnet

Atkins, L. (2010) NHS 'must lessen trauma of miscarriages' Parents web forum Mumsnet calls for new code of practice to help women who lose their babies, The Guardian, Tuesday 2 March.

Review: iii Fundamentals of Person-Centred Healthcare Practice

 

Previously, I recognised the many links throughout the book and on p.54 there are five relating to professional standards. These reflect the book's international scope and multidisciplinary relevance. Those on page 54 do work and support the text. One of them I was presented not with the expected page and missed the outcome of the 'click'. I wasn't going to re-type but found the page through the site's menu. Some links are long, as I found, whether permalinks [usually shorter] or fallback search text might improve link-longevity I'm not sure.

As a reassurance the contrast issue black-text-on-dark-green is limited to one figure.

The book is well referenced with an additional reading list. I've been made aware through plagiarism detectors (one paper) which - it appears - have 'read' an introductory section to Hodges' model as self-plagiarism. I wondered if in comprising a community of practice the references here maybe somewhat insular. I've no analysis to support this and the same no doubt may apply to other to emergent ideas, including threshold concepts. You have to start somewhere. At fear of contradiction there are many theories called upon and referenced.

Students may find the more attention to the position and specificity of references useful p.75 "we cannot not communicate." How times, chapters (8 - Communicating and Relating Effectively), theory, practice and management are challenged. The art of  'sympathetic presencing' working on the phone triaging acute community mental health referrals, 'Being kind and warm'.

For a text on person-centredness the book is imho mental illness-health light, but then as noted what is the book about? Am I suggesting that such books should attend to disciplinary equality? That said if there is a test for parity of esteem here, what do you conclude from one dedicated chapter? I was surprised, but is there a dilemma here? Beside 'Trust in self and others' I made a note, 'intuition'. Is person-centredness and being person-centred taken for granted within mental health practice? Research suggests not. 

Reading the table of contents you will find:

Chapter 18: Being person-centred in the acute hospital setting
Chapter 19: Person-Centred Rehabilitation
Chapter 20: Being person-centred in community and ambulatory services
Chapter 21: Experiencing person-centredness in long-term care
Chapter 22: Being person-centred in mental health services
Chapter 23: Person-centred support for people with learning disabilities
Chapter 24: Being Person-centred in Maternity Services
Chapter 25: Being person-centred in children’s services
Chapter 26: Being person-centred when working with people living with long-term conditions
Chapter 27: Palliative and end of life care services

I had a sense that the chapters were not sufficiently differentiated despite the titles. This may say more about my reading and the (editor's achieved) coherence of the book overall. Perhaps also for me, person-centredness is realised in-situ with personalised details. Not just vignettes (which are used) but the detailed intra- interpersonal, social, physical, political and spiritual choreography that is person-centred care: whether or not there is engagement (a dance).

Dementia is represented but the context appears to be residential care. You will find challenging / courageous conversations, but not challenging behaviour in situations that test interpersonal skills and person-centredness especially for staff, students, carers and families (dementia in general hospitals - despite numerous initiatives). Trauma has its place in the mental health chapter (and in current literature), but again the challenge of psychoses, anorexia are missed opportunities to reveal the potential and delivery of the Person-Centered Practice Framework.

Since the book's publication with its stress on the welfare and well-being of staff and educators too, the need to make explicit the politics in health is even more extreme. The need to protect the title of 'nurse'; mis-information generally and relating to COVID. Person-centred decision making and shared decision making are described as systems. Perhaps this misses the nuances of a health care professional, the team and family working with a person were they are making an unwise decision (pp.83-92). Another chapter indicates the need and utility of disciplinary bridges:

Chapter 17: Socio-political context in Person-centred Practice

 

individual - PERSON - patient
|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

family - group - population

MIND :: Parity -	- of esteem :: BODY
Culture Child - Parent - Guardian FAMILY SOCIO -	Refugees Homeless title of 'nurse'* mis-information Organisational culture? - POLITICAL

One more to follow with many thanks to the publisher for the review copy.

Review i

Review ii

Review iv

Fundamentals of Person-Centred Healthcare Practice,  McCormack, B., McCance, T., Bulley, C., Brown, D., McMillan, A, Martin,S. (Eds.). ISBN: 978-1-119-53308-5 February 2021 Wiley-Blackwell.

* https://twitter.com/hashtag/ProtectNurse?src=hashtag_click