Publication of long-awaited maternity care report sets out “blueprint for care”

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A long-anticipated report into serious maternity care failures at Shrewsbury and Telford Hospital NHS Trust (SaTh) has finally been published today (30 March 2022).

Senior Midwife Donna Ockenden who led the review says it sets out a “blueprint for safe care”.

The publication of the Ockenden independent maternity review follows two delays: one in December 2021, when it was originally due to be published, and another earlier this month, which was blamed on ‘parliamentary processes.’

Ockenden was originally asked to investigate 23 cases, but these escalated rapidly to the point where 1,486 families came forward with concerns about the care they received.

The 5-year investigation has reviewed the experiences of those families that took place within the Trust between 1973 and 2020.

The report includes not only the voices of the families involved but also the staff who worked there.  In 2021, the review team interviewed 60 present and former members of staff about their opinions on SaTH’s maternity services.

An interim report was published in December 2020, which revealed that SaTh had blamed some mothers for their babies’ deaths. It also found that a drug to induce labour was frequently misused and that maternity deaths were often not properly investigated.

Throughout the review of 1,486 family cases, the review team has identified thematic patterns in the quality of care and investigation procedures carried out by the Trust and identified where opportunities for learning and improving quality of care had been missed.

The team considered all aspects of clinical care in maternity services including antenatal, intrapartum, postnatal, obstetric anaesthesia and neonatal care.

The key findings of the Ockenden report

Today’s report reveals the full extent of the inadequate care delivered by the Trust, including:

  • In 12 cases of maternal death considered by the review team none of the mothers had received care in line with best practice at the time. In three-quarters of the women, their care could have been significantly improved. Only 1 maternal death investigation was conducted by external clinicians, and the internal reviews were rated as poor by the review team. These internal investigations frequently did not, recognise system and service-wide failings to follow appropriate procedures and guidance. As a result, significant omissions in care were not identified and in some incidents women themselves were also held responsible for the outcomes.
  • In 498 cases of stillbirth, 1 in 4 were found to have significant or major concerns in maternity care, which if managed appropriately might, or would have, resulted in a different outcome.
  • Staff were overly confident in their ability to manage complex pregnancies and babies diagnosed with foetal abnormalities during pregnancy, with reluctance to refer to a tertiary unit to involve appropriate specialists.
  • A failure to refer or discuss issues with colleagues from the wider multidisciplinary team, with repeated failures to escalate concerns in both antenatal and postnatal environments. This resulted in some families being discharged from hospital but later readmitted for emergency procedures due to becoming extremely unwell through the lack of earlier appropriate review of care.

Throughout the various stages of care the review team identified a failure to follow national clinical guidelines whether it be for the monitoring of foetal heart rate, maternal blood pressure, management of gestational diabetes or resuscitation. This, combined with delays in escalation and failure to work collaboratively across disciplines, resulted in the many poor outcomes experienced by mothers or their babies, such as sepsis, hypoxic-ischaemic encephalopathy and unfortunately, death.

Local Actions for Learning and Immediate and Essential Actions

In total, more than 60 Local Actions for Learning have been identified specifically for the Trust considering the care received by the families featured in the review.

It is, however, recognised that many of the issues highlighted in the report are not unique to SaTH and have been highlighted in other local and national reports into maternity services in recent years.  Therefore, the review team has also identified 15 areas as Immediate and Essential Actions which should be considered by all Trusts in England providing maternity services.

These include the need for significant investment in the maternity workforce and multi-professional training; suspension of the Midwifery Continuity of Carer model until, and unless, safe staffing is shown to be present; strengthened accountability for improvements in care amongst senior maternity staff, with timely implementation of changes in practice; and improved investigations involving families.

The report identifies an urgent need for a robust and funded maternity-wide workforce plan and for the present and future requirements for midwives, obstetricians, anaesthetists, neonatal teams, and associated staff working in and around maternity services to be addressed. Without this, maternity services cannot provide safe and effective care for women and babies. Only with a robustly funded, well-staffed and trained workforce will staff be able to ensure delivery of safe, and compassionate, maternity care locally and across England.

Donna Ockenden has identified 4 key pillars to drive forward improvements in maternity services not only at SaTh, but all other Trusts in England.

These are:

  1. Safe staffing levels that are properly funded
  2. A well-trained workforce
  3. Learning from incidents
  4. Listening to families

While progress has been made in some of these areas, there must be a fully funded and concerted effort by all NHS Trust across England to ensure that all these 4 pillars are the foundation, the roadmap and the blueprint of all maternity services moving forwards.

Donna Ockenden notes:

We recognise that maternity services have very significant workforce challenges, and this must change. Clearly, workforce challenges that have existed for more than a decade cannot be put right overnight. However, it is our belief that if the ‘whole system’ underpinning maternity services commits to implementation of all the Immediate and Essential Actions within this report with the necessary funding provided then this review could be said to have led to far reaching improvements for all families and all NHS staff working within maternity services.”

Hannah Carr, a medical negligence solicitor from Novum Law’s Salisbury team who specialises in women’s health and birth injuries, has been reviewing the report. She says:

“Today will be hugely difficult time for families directly affected by what happened at Shrewsbury and Telford Hospital NHS Trust, and for anyone with personal experiences that relate to the issues the report covers.  It will also be a challenging day for healthcare professionals.  No doubt some of the findings will be difficult to hear, but the recommendations of the report should be read in a spirit of acceptance and learning.

“What is clear is that parents’ voices were silenced.  Those families have been brave, patient, and persistent in getting their voices heard.  I cannot begin to imagine where their strength comes from to endure losing a child (or children) and then to campaign tirelessly for answers.  However, there is hopefully some degree of solace in knowing that what happened to them and their babies will create a legacy of safety moving forwards. 

“It is going to be vital for those involved in delivering maternity care to work together with a shared goal and vision for the future.  There is no space for defensive and divisive attitudes. Compassion is the way through.

“I stand in solidarity with all those who campaign for truth and absolutely support the need for positive change that enables those working within maternity services to provide the standard of care that protects families.”

If you have any concerns about the treatment you and your baby have received in a hospital or any other healthcare setting, Novum Law’s team of specialist medical negligence solicitors can help on a no-win, no fee basis. To find out more information, contact us on Freephone: 0800 884 0777 or email:

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