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Why Ockenden might have been predictable (and maybe preventable)

This month saw the publication of the long awaited Ockenden report exposing patient harm in maternity services in Shrewsbury and Telford Hospital NHS Trust.

The report exposes a paternalistic culture, tribalism between different professions and a target driven culture.

One of the findings is that women were often not listened to and that their concerns were ignored.

This is not the first and unlikely the last report that will highlight these type of findings in the way a healthcare institution and its staff interact with patients.

These type of occurrences seem to come in painfully predictable intervals. Knee-jerk reactions have been equally predictable: the threat of holding those responsible to account, creating new checks, reviewing existing governance procedures ... Given how predictable and uniform events and response are if would seem that a more fundamental change in the way we think about care is needed.

Decision making at the unit in question was dictated by a culture that was hierarchical at both meso and micro-level. Patients were often given little choice and had no means to fight back: they did not know the guidelines that should have guided their care, what normal care should look like and what standards were acceptable and what alternatives might be. They could not document their pain, their concerns, and their findings as part of the official records and legal narrative of care. They were powerless till they arrived in court.

In the age of personal health records, widely available resources online and shared decision making aids they should have had more power to determine their care and steer professionals towards the type of care that supported them best.

Maybe most paperwork is the answer for some of the health services cultural problems, but this time around it should not be more paperwork for healthcare professionals, but better, more transparent information systems for patients to prevent the next Ockenden, Stafford and Bristol.

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