Yesterday saw the release of the long-awaited report from Donna Ockenden, Senior Midwife, addressing maternity care at Shrewsbury & Telford Hospital NHS Trust between 2000 and 2019 (“The Ockenden review”).

In 2016 the review team was commissioned by the government to carry out an independent review of the Shrewsbury & Telford NHS Trust. Initially, the review focused on 23 cases of concern, but over time the investigation grew to encompass almost 1,600 clinical incidents and 1,500 families.

The Ockenden review comes against a background of an increased focus on maternity care in recent years, including the launch of the National Maternity Safety Ambition, a government initiative to reduce the rate of stillbirths, brain injuries, neonatal and maternal deaths by 50% in England by 2025.

The Ockenden team made some alarming findings, including:

• Of 12 cases of maternal death that were reviewed, the review team found that none of the mothers received care in line with best practice and that in some cases the women themselves were held responsible for the outcomes;
• 498 stillbirths were reviewed, and 1 in 4 cases were found to have significant or major concerns in maternity care that, if managed appropriately, might or would have resulted in a different outcome;
• there were significant concerns in almost two-thirds of cases involving babies born with brain injury caused by oxygen deprivation to the brain; and
• There were significant or major concerns about the care in nearly a third of incidents involving neonatal deaths.

The team also found that there had been various failures in governance and leadership and that investigatory procedures were not followed to a standard that would have been expected.
The report makes various recommendations to improve care and safety maternity services across England, including:

• A significant increase in the budget for maternity services
• Ring-fencing a proportion of maternity budgets for training in every maternity unit
• The need to learn from patient safety incidents, endorsing the Health Select Committee’s findings that families must be involved in the process and that lessons must be learned and implemented in a timely way to prevent further tragedies.

The stories of the families involved in the review are heart-breaking, and the Ockenden review reflects the tireless efforts of the families who have suffered as a result of the trust’s failures. Both myself and the clinical negligence team at JMW deal with a significant number of cases involving avoidable harm to babies, and sadly there are clinical incidents occurring nationwide similar to those highlighted in the Ockenden report. However, it is hoped that the report’s findings will shine a spotlight on maternity services across the country and that changes will continue to be made throughout the NHS to ensure improvements in maternity services.