What is the Ockenden Review?

The Ockenden Review is an inquiry into maternity services at Shrewsbury and Telford Hospitals NHS Trust (SaTH). It was launched in 2017 after the families of Kate Stanton-Davies and Pippa Griffiths, who both tragically died a few hours after they were born, wrote to the health secretary at the time, Jeremy Hunt, because of concerns about the maternity care at SaTH. Kate and Pippa’s deaths were later found to have been avoidable.

The Review of the maternity services at SaTH considered “all aspects of clinical care in maternity services including antenatal, intrapartum, postnatal, obstetric anaesthesia and neonatal care”.

What is the purpose of the Review?

Serious complications and deaths resulting from failures in maternity care have a devastating and lifelong impact on families and their loved ones. The priority of the Ockenden Review “has been to ensure that the families impacted by the maternity services at the Trust are heard”. It has been reported that families tried to speak out about the care that they received at SaTH in the years before the Ockenden Review began but they were silenced or ignored.

The families involved wanted to “understand what had happened to them, as well as ensure that finally lessons are learned so that no further families experience the same harm and distress that they did”.

The review team also made sure that staff members at SaTH had the opportunity to be heard.

Who is conducting the review and what is being investigated?

The inquiry started in 2017 with 60 incidents of newborn, infant and maternal harm at SaTH but that number has since risen to 1,592, as more and more families reported concerns about the maternity care that they received at SaTH. The incidents range from 1973 to as recent as 2020, and some families reported multiple incidents of harm. It is the largest review of maternity care in the history of the NHS.

The inquiry is being led by Senior Midwife, Donna Ockenden, and her team of 90 midwives and doctors. Ms Ockenden and her team have examined every case reported to them, many of which concern children who sustained life changing injuries because of failures to provide adequate treatment, and many in which babies tragically died before or shortly after they were born.

The inquiry’s initial report was published in December 2020 and highlighted the experiences of families in 250 cases. The report’s findings were shocking, and it recommended several “Immediate and Essential Actions to Improve Care and Safety in Maternity Services”.

The second Ockenden Report – March 2022

The second report of the inquiry (The Ockenden Report) was delayed but has now been published. The review team has identified patterns in the quality of care and investigations provided by SaTH and has also identified areas where there have been missed opportunities to improve quality of care and learning.

The inquiry found repeated “errors in care”, which led to injury to mothers or babies. On several occasions, the injuries were found not to have been isolated incidents and would have been avoided if lessons had been learned from previous cases.

The Review found that there were significant or major concerns regarding the following:

• 12 incidents of maternal death.
• A quarter of incidents of stillbirth.
• Almost a third of incidents of neonatal deaths.

The report sets out several concerns about the care provided during the review period, including over-confidence of staff in dealing with complex or high-risk pregnancies, failures to refer women to colleagues and escalate concerns in antenatal and postnatal environments, and delays in women on the labour ward being investigated for emergency intervention.

The review team identified that there were failures to follow national clinical guidelines regarding “monitoring of fetal heart rate, maternal blood pressure, management of gestational diabetes, and resuscitation”.

The report criticises the culture among the maternity staff at SaTH staff and found that the relationship between midwifery and obstetric staff was “them and us”, which led to fears about escalating concerns. Many parents reported a lack of compassion from staff at SaTH while they were receiving care, during follow-up and in relation to complaints.

One of the most concerning findings was that there was often a lack of available clinical expertise, which led to staff being overstretched and inexperienced locum doctors being called upon, who were then unsupported, and this could cause “unsafe clinical practice”. Staff were reported to often feel “fearful and stressed at work due to poor staffing levels”.

It was found that investigatory procedures were often not followed and regularly did not identify underlying systemic failings. Serious incidents were often inappropriately downgraded to avoid external scrutiny. These factors meant that throughout the review period, lessons were consistently not learned, and mistakes were repeated.

The Review has identified more than 60 Local Actions for Learning in light of the incidents considered. It is encouraging to note that since the first Ockenden Report in December 2020, it has been reported that there has been an improvement in maternity care at SaTH.

The report can be found here – OCKENDEN REPORT – FINAL (ockendenmaternityreview.org.uk)

What will be the outcome of the Ockenden Review?

It is hoped that the maternity services at SaTH will continue to improve. The NHS missed repeated opportunities to deal with the problem at SaTH and there are currently reviews into maternity care in Nottingham, East Kent, and South Wales. Concerns have also been raised about maternity services in Derby due to low staffing levels.

At Moosa-Duke Solicitors, we hope that the Ockenden Report will be a catalyst for real change in maternity services across the NHS.

If you have concerns about the maternity care that you or a family member has received, please contact our specialist team for a no-obligation consultation on 0116 254 7456 or at enquiries@moosaduke.com.