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RCOG response to NHS Improvement report on the handling of an invited review of maternity services at Shrewsbury and Telford

News 22 July 2020

NHS Improvement has published an investigation into the handling of an RCOG invited review of maternity services at The Shrewsbury and Telford Hospital NHS Trust.

In December 2019 NHS Improvement’s medical director wrote to families confirming that the investigations team would look into the concerns they had raised in relation to the Trust’s handling of the invited review and inform them of any action taken.

NHSI has published the review document here and expects The Shrewsbury and Telford Hospital to act on the recommendations to provide safer and improved care for patients and their families.

Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said:

“We welcome this thorough investigation by NHS Improvement which confirms that our invited review remained materially unchanged from when it was originally submitted to the Trust in October 2017.

“While any decision around the dissemination of an invited review report remains the responsibility of a hospital Trust or Board, this NHSI investigation demonstrates that these reports should be shared promptly to ensure openness and transparency.

“As a College, we remain deeply committed to driving improvements in women’s health services. We will continue to work with maternity services, regulators and other key partners to ensure women and their babies receive only the very best care and support.”


Note to Editors

For media enquiries, please contact the RCOG press office on 020 7045 6773 or email

  • In March 2017, the Medical Director of the Shrewsbury and Telford NHS Trust requested the RCOG undertake an invited review of their maternity services, following concerns over perinatal mortality. The review did not focus on these deaths retrospectively - these are, however, the focus of other independent investigations.

  • Based on this review, which was conducted in July 2017, the RCOG made 37 recommendations to ensure maternity and neonatal services were safe and effective for mothers and their babies. These included recommendations on how care is organised and provided, and how to promote a culture of shared learning among health care staff from serious incidents investigations to improve maternity safety.

  • The Trust requested a follow up meeting with the RCOG to discuss the report in February 2018 and a further table top exercise in April 2018. During this exercise, the Trust shared improvements that had been made since the RCOG conducted its review.

  • A summary of the 2018 meeting, in which the RCOG stated that there was still work in progress to ensure maternity services were meeting the needs of women and babies, was shared with the Trust who published it as an addendum to the full 2017 report. The initial report and the addendum were published together by the Trust in July 2018.

  • The RCOG invited review report, and the addendum are available on the Shrewsbury and Telford Hospital NHS Trust website.

  • The RCOG is committed to working with hospital trusts to provide safe and sustainable services that improve outcomes for babies and mothers. For more information about the invited review services, please visit our website.

  • The RCOG follows the Academy of Royal Medical College’s framework of operating principles for managing invited reviews within healthcare.

  • Since 2018, to ensure patient safety, the RCOG has been informing relevant regulators of all invited reviews it agrees to carry out, and sharing the final reports with the regulators.