James Watts, consultant in anaesthesia and critical care medicine at East Lancashire NHS Trust discusses the Ockenden Report and the role of the obstetric anaesthetist.
In 2016, Donna Ockenden, former Clinical Director of Midwifery at the London Strategic Clinical Network at NHS England, was commissioned by Jeremy Hunt, then Secretary of State for Health, to Chair an Independent Review into maternity services at the Shrewsbury and Telford Hospitals NHS Trust (SaTH) following a series of well publicised concerns. These concerns included excess mortality of both babies and mothers.
In the end, the initial review committee considered 23 deaths; was later widened to consider 60 patients; and then in 2019 revised again by the new Secretary of State, Matt Hancock, to consider hundreds of cases where care was feared to have been substantially poor.
Her final report was published in 2022, having considered 1486 family experiences of 1592 reported incidents that had occurred between 1973 and 2020; 84 staff questionnaires; and 60 staff interviews. Notably, some staff asked their comments to be deleted from the report due to fears they would be identified and targeted by management. (1)
Common themes identified were missing warning signs, failure to act appropriately when they were detected and failure to recognise or learn meaningfully from these issues. The sheer number of incidents occurring should have rung alarms, but red flags were missed because of repeated turnover at senior management level. It is reported that the Obstetric department rejected the findings of an RCOG review and resorted to defensive silo working. A former executive board member reportedly said it was a ‘…Republic of Maternity, where, often, the maternity service seemed to consume its own smoke, and didn’t like having oversight by the corporate team…there was a disconnect both ways actually, I believe, from the corporate team to maternity and maternity to the corporate team’. This meant that the recommendations of external reviewers (and there were several before the crisis broke) could not be implemented.
The report itself said:
‘….throughout the review period staff were overly-confident in their ability to manage complex pregnancies and babies diagnosed with fetal abnormalities during pregnancy. There was sometimes a reluctance to refer to a tertiary unit to involve specialists such as paediatric surgeons and geneticists in care….the neonatal unit at Royal Shrewsbury Hospital continued to work as a neonatal intensive care unit for many years after it had been re-designated as a local neonatal unit. … Internally, within maternity services at the Trust women were frequently not referred to or discussed with colleagues from the wider multidisciplinary team. It has been observed that there were repeated failures to escalate concerns in both antenatal and postnatal environments…… The review team has also heard directly from staff that there was a culture of ‘them and us’ between the midwifery and obstetric staff, which engendered fear amongst midwives to escalate concerns to consultants. This demonstrates a lack of psychological safety in the workplace, and limited the ability of the service to make positive changes.’
The report comes on the back of other reviews of NHS maternity services including Northwick Park (10 maternal deaths between 2002 and 2005 with causes including poor leadership, toxic staff culture and staff shortages) (2); and Morecambe Bay Trust ( ‘the Kirkup report’: avoidable deaths of 11 babies and 1 mother between 2004 and 2013 due to poor working relationships between specialties and a toxic over promotion of natural childbirth by a cadre of midwives (3)
Rhiannon Davies, one of the mothers whose efforts led to the Ockenden review stated, ‘There is a cultural problem nationally in maternity. We need to have a more grown-up conversation about the risks of pregnancy. No one ever wants to think about death in maternity’ (4). This is a statement that crystallises the core of one of the most important issues in maternity practice: one cannot assume just because something is a ‘natural’ process that it is also an inherently ‘safe’ process. Whilst it is important that over medicalisation of delivery and labour is avoided, to provide a good experience for the mother and a good outcome for the mother and baby, close working relationships between different professional teams is key.
It has always been recognised that anaesthetists have a key role in the delivery of safe services to the labouring mother . The most recent guidelines which were published by the OAA and AAGBI (5) made the following recommendations:
- Consultant anaesthetist presence should reflect both the volume and complexity of clinical work and administrative requirements as well as support from staff grades and trainees
- The goal should be that obstetric services should move towards being fully consultant delivered
- There should be sufficient consultant and anaesthetic presence such that emergency work does not impinge upon elective obstetric work; this includes labour ward staffing
- The duty anaesthetist should be immediately available (i.e. within 5 minutes except in exceptional circumstances) and should not be distracted by external duties
- In midwifery led units where there is regional anaesthesia delivered:
- there must be a Consultant led obstetric service on site
- appropriate guidelines must be in place
- midwifery staff must agree to follow the anaesthetic guidelines
- the midwife must allow the anaesthetist access to any woman considering regional analgesia who wishes to discuss pain relief options
- If the anaesthetist feels that an obstetric opinion is necessary, they should consult the midwife in the first instance, but, if necessary, they may consult directly with the obstetricians, but should inform the midwife that this is their intention
- there must be a Consultant led obstetric service on site
- Working relationships with obstetricians
- Anaesthetists should encourage and facilitate consultation in the antepartum period by making themselves available when antenatal clinics are in progress and by ensuring clear lines of referral.
- A system for the antenatal assessment of high-risk mothers should be in place with 24-hour access to the information on the delivery suite
- Good communication on the delivery suite is vital in order to minimise last-minute referral and the hasty decision-making that often ensues.
- Anaesthetists should make themselves known to obstetricians who should, in turn, keep them informed of developing problems.
- Anaesthetists’ attendance at obstetric ward rounds is to be encouraged in order to be kept well informed of the labour ward caseloads and casemix
- There should be formal arrangements in place and protected time for multidisciplinary handover at the beginning and end of each shift
- Anaesthetists should be involved in planning decisions that affect the delivery of maternity services.
- Anaesthesia should be represented on any committee that has relevance to anaesthetic services on the labour ward such as the labour suite working party, obstetric directorate and risk management forum.
- Neonatal resuscitation Units differ as to their policies about the involvement of the anaesthetist in neonatal resuscitation. Where they are given a role, anaesthetists should work with the neonatal team to ensure that appropriate training is delivered and maintained
Therefore, the guidance painted broad parameters as to the responsibilities and duties of Obstetric anaesthetists; although it was unclear how publicised they were outside of anaesthetic circles. (6)
One of the main conclusions of the Ockenden report was that although staff and resources were overstretched mothers who would be best served having a surgical delivery should not be but under pressure to continue with a natural childbirth when it was not in their best interests or the best interests of the child. (1. 7.8)
The monitoring of the progress of pregnancy and labour is delegated to the midwifery profession, who can activate the intervention of Obstetricians and other professions when indicated. All the reviews discussed above noted that a defensive culture dedicated to natural childbirth at all costs was contributory to these failures and was central to dysfunctionality of services leading to a schism between midwives and other specialties, and division between different medical specialties.
However, Ockenden’s report is the only of these reviews to specifically consider the role of the Obstetric anaesthetist. The report conclusion stated:
‘…Other examples of a lack of appropriate escalation are of obstetric anaesthetists involved at the last minute, not enabling them to assess women appropriately for urgent obstetric interventions…’
For the first time outside of anaesthetic circles the report has clarified and defined the role of the Obstetric anaesthetist:
‘The role of the anaesthetist on duty for obstetric anaesthesia is much broader than being merely a technician for provision of pain relief and anaesthesia. They must also work as part of the multidisciplinary team in the management of women experiencing pregnancies or childbirth, complicated by certain obstetric issues or pre-existing medical disease.’
Sadly, the review team found that anaesthetic intervention at SaTH was not pro-active, but generally task focussed, and filtered through midwife or obstetrician requests. Whilst there was a clear need for anaesthetic intervention in labour and delivery, the report stressed the need for anaesthetic input in the post delivery phase of care, particularly when a patient was unwell. These included decisions about the correct location for post delivery care which were often obscure if they were made at all
The report said:
‘As well as occasions where anaesthetists failed to involve themselves in the care of critically ill women, there were cases where the obstetric and midwifery teams failed to involve or inform the anaesthetist on duty about women with significant morbidity. Often the anaesthetist was only called to review a patient once a decision had been made to take them to theatre, sometimes for very urgent surgery, thus denying the anaesthetist the opportunity to make a considered assessment of the patient and to take steps to optimise the patient’s condition prior to anaesthesia…’
The report stated that there were no clear indications as when to call an anaesthetist to review a patient at any stage of their labour, and that when they were called there was no guidance as to when escalation to a more senior opinion was appropriate. The report stated that the level of Obstetric staffing was not compliant with OAA recommendations with rota gaps increasing, and no real attempt made by the trust to address the shortfall other than by locum employment. Common conditions were not recognised, and when recognised, not treated correctly. Anaesthetic charts were frequently ‘patchy’, and whilst on paper there were shared audit activities anaesthetic attendance what at best infrequent.
The report concluded:
‘Outpatient postnatal follow-up by an anaesthetist must be offered for women for whom significant issues have occurred, especially where they may impact on anaesthesia management or anxiety during future childbirth. Such issues include inherent anaesthetic complications such as intraoperative pain, including where conversion to general anaesthesia became necessary, suboptimal epidural pain control with significant consequent distress, and postdural puncture headache. More serious complications such as awareness under general anaesthetic and neurological complications related to anaesthesia must also be followed-up in an outpatient setting. Clinicians must also recognise situations where women would benefit from a conversation and explanations regarding their anaesthetic care even when nothing has actually gone wrong. Provision of such appointments must be seen as part of a culture of openness.
The report confirms the fact that Obstetric Anaesthetists have much knowledge and experience to contribute to the care of patients and the safety of the Maternity Unit. Rather than interlopers whose role is confined to esoteric methods of pain relief, they are an essential pool of knowledge and experience for pre, intra and post partum care. Whilst the full burden of safety and efficiency should not be shouldered by the anaesthetic team, they have a key role to play in the maintenance of standards and care, and should be a valued part of the multi-disciplinary team, and be able to provide clear leadership in situations where ‘minutes, or even fractions of minutes, can make the difference between triumph and disaster.’ (9)
In summary, the Ockenden report clearly outlines the importance of a coherent and team approach to the management of maternity cases, and emphasises that a pro-active dedicated Obstetric anaesthetic team is a key part of safe patient management. The role of the Obstetric anaesthetist stretches from the ante natal to the post natal period. Whilst anaesthetists should not accept the full burden of responsibility for governance on the Obstetric unit, they should be pro active and the driver of high standards of patient care.
- The Ockenden report. Findings Conclusions and Essential Actions from the Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust March 2022 HM Stationary
- An independent review of serious untoward incidents and clinical governance systems within maternity services at Northwick Park Hospital 16/09/2018 https://moderngov.harrow.gov.uk/documents/s30776/Maternity%20Review%20Report.pdf
- The Report of the Morecambe Bay Investigation March 2015 Dr Bill Kirkup CBE March 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf
- Shaun Lintern, ‘They condemned my daughter to death’: The family whose fight for justice uncovered the Shrewsbury maternity scandal, The Independent, 19 November 2019. Accessed 22 December 2020.
- OAA / AAGBI Guidelines for Obstetric Anaesthetic Services 2013 June 2013https://www.oaa-anaes.ac.uk/assets/_managed/editor/File/Guidelines/obstetric_anaesthetic_services_2013.pdf
- Van den Driesen NM Lim W Paech MJ labour ward midwifery Staff Epidural Knowledge and Practice Anaesth Int Care 1998 411-419Hunt, Jeremy (2022). Zero. London: Swift Press. p. 253. ISBN9781800751224
- Hunt J Zero: Eliminating unnecessary deaths in a post-pandemic NHS swift Press 2022
- “The NHS is still not learning from past mistakes in maternity”. Health Service Journal. 5 April 2022. Retrieved 17 June 2022
- McCombe K Bogod DG Learning from the law: a review of 21 years of litigation for anaesthetic negligence resulting in peripartum hypoxic ischaemic encephalopathy Anaesthesia 2022 77:919-928