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An independent review of maternity services at an NHS trust has called for urgent changes to prevent further avoidable mother and baby deaths, and injuries including brain damage, after devastated families demanded an inquiry.

The report into the level of care at the Shrewsbury and Telford Hospital NHS Trust in Shrewsbury, England laid bare the painful experiences of families whose pregnancies ended with avoidable instances of stillbirth, newborn brain damage and the deaths of both babies and mothers. 

The inquiry was launched after families who’d gone through the “incomprehensible pain” caused by failures in patient safety demanded an investigation to highlight what they went through, and to make meaningful changes to save lives in the future. 

In a letter to Health Secretary Matt Hancock attached to the report, the review highlighted a number of key issues they believe should be urgently shared with all NHS maternity services, as well as requesting critical oversight of patient safety to combat existing failures.

The recommendations included ensuring NHS hospitals work together on serious incidents and secure expert advice when one occurs, as well as appointing a non-executive director to the board of NHS trusts to promote women’s voices and consider their experiences. The Ockenden review was ordered three years ago by the UK government after the families of two children who died while under an NHS trust’s care raised serious concerns about the maternity treatment they and 21 others received.

Nadine Dorries, minister of state for patient safety, responded to the report on Thursday by saying: “I expect the trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families.” 

This is the first section of the report that is set to be released by the Ockenden Maternity Review, with this document offering recommendations for issues that require immediate action. A full report is expected at a later date, and will further examine areas that require improvements to protect patients in maternity care. 

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