The Ockenden report into maternity care failures: our reaction

Wed 30th Mar 2022

Coodes Partner and Clinical Negligence Specialist Julie Hatton has praised the families at the heart of the investigation into maternity care failures at Shrewsbury and Telford Hospital NHS Trust following the publication today of a full report by midwife Donna Ockenden.

Here Julie outlines reactions to the report, and discusses the impact of its findings.

The Ockenden report

At least 201 babies and nine mothers may have died as a result of catastrophic maternity failings at Shrewsbury and Telford Hospital NHS Trust.

In 94 cases, babies suffered avoidable long-term injuries, including brain damage, due to a lack of oxygen during their birth.

Some mothers were even blamed for their own deaths.

The review examined almost 1,600 cases spanning 20 years and is thought to be largest of its kind in NHS history.

There’s a lot to process in this damning report and many, much wider implications for maternity services across England.

But at the heart of this unprecedented investigation was the courage and conviction of bereaved families who had to fight all the way for an inquiry.

Key findings

The damning review by senior midwife Donna Ockenden’s examined catastrophic failures in maternity care at the Shrewsbury and Telford NHS Trust (SaTH).

She also said it was “astounding” that the issues had not been challenged for more than two decades and that the Trust was not held to account by external bodies.

Key findings include:

  • A culture where mistakes were not investigated and a failure of external scrutiny
  • Parents were not listened to when they raised concerns about the care they received
  • Where cases were examined, responses were described as lacking “transparency and honesty”
  • The trust failed to learn from its mistakes, leading to repeated and almost identical failures
  • A culture of bullying, anxiety and fear of speaking out among staff at the trust “that persisted to the current time”
  • Caesarean sections were discouraged, often leading to poor outcomes

Strength of feeling

The inquiry was first commissioned in 2017 following a campaign by two families who had lost their babies.

Richard Stanton and Rhiannon Davies’s daughter Kate died hours after her birth in March 2009, while Kayleigh and Colin Griffiths’ daughter Pippa died in 2016 from a Group B Streptococcus infection.

I have a huge admiration for these parents and what they’ve been through. When you’re in a hospital setting, you go with what you’re being told. You trust what’s happening, you trust what’s going on around you and you put your trust in the professionals.

It’s not until afterwards that you start to question what’s happening. That’s exactly what these families did.

A difficult process

The families must have gone through an incredibly tough time in the past few years as the inquiry unfolded.

I know from my experience with clients that sticking to your guns when you’re up against organisations and you don’t know the jargon is difficult. But often you’ve got this gut feeling that something wasn’t right.

One of the things I hear a lot is people saying: ‘I don’t want this to happen again. I don’t want someone else to go through what I’ve been through. I want to know that measures have been put in place and that changes are going to be made’.

What will it mean for the future?

This latest report issues more than 15 immediate and essential actions for all maternity services in England, covering ten key areas, including:

  • Financing a safe maternity workforce
  • Maintaining a clear escalation and mitigation policy when agreed staffing levels are not met
  • Essential roles for Trust Boards in oversight of their maternity services:
  • Meaningful incident investigations with family and staff engagement and practice changes introduced in a timely manner
  • There must be mandatory joint learning across all care settings when a mother dies
  • Care of mothers with complex and multiple pregnancies
  • Ensuring the recommendations from the 2019 Neonatal Critical Care Review are introduced at pace
  • Improving postnatal care for the unwell mother: All trusts must develop a system to ensure consultant review of all postnatal readmissions, and unwell
  • Care of bereaved families


Reaction in the media has been widespread, with many people, including ex-Health Secretary Jeremy Hunt, who originally ordered the inquiry in 2017, saying that the scandal was far worse than imagined.

Health Secretary Sajid Javid said the Ockenden report painted a ‘tragic and harrowing’ picture of repeated failures in care over two decades.

Shrewsbury and Telford Hospital NHS Trust’s chief executive Louise Barnett apologised for the pain and distress caused to families by failures.

‘Today’s report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust,’ she said.

‘We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.’

So, what now?

Like many, I hope something positive comes from all of this, for the sake of the families involved here and for others across the country.

There is a great deal of information in the Ockenden report about the kinds of incidents that can and do happen.

If people are reading about these types of incidents in the news or if they read the full report, they might know somebody who has had a similar experience. It will certainly help to raise awareness to make sure nothing like this can happen again.

If it hadn’t been for the hard work and courage shown by these families, then an awful lot of people wouldn’t have got the answers they deserved.

For further information or advice on these issues please contact Julie Hatton in Coodes Solicitors’ Personal Injury and Clinical Negligence team on 01326 214036 or

Wed 30th Mar 2022

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