Ockenden report: Findings into the biggest NHS maternity scandal at Shropshire hospitals released
The Ockenden inquiry investigated more than 1,500 cases at Shrewsbury and Telford Hospital Trust
Last updated 30th Mar 2022
A long-awaited report into the biggest maternity scandal in the history of the NHS at hospitals in Shropshire has been released.
The Ockenden report, led by senior midwife Donna Ockenden, was set up following the deaths of newborn babies and mums at Shrewsbury and Telford NHS Trust. They occurred mostly between 2000 and 2019.
After its release this morning, the report's found mothers and babies died or suffered major injuries due to "repeated failures" at the NHS trust.
It says Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years - and did not learn from its own inadequate investigations - which led to babies being stillborn, dying shortly after birth or being left severely brain damaged.
Several mothers died after failings in care, while others were made to have natural births when they should have been offered a Caesarean.
Injuries for some babies included skull fractures, broken bones or they developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.
The damning report involved more than 1,400 families and reviewed 1,592 clinical incidents. with recommendations for improvements at Shropshire hospitals managed by the trust, like The Royal Shrewsbury and The Princess Royal Hospital, and across the country.
As well as major issues within the trust, the report pointed the finger at external bodies, which did not effectively monitor the care provided.
Where investigations did take place, they did not meet expected standards and failed to identify improvements, meaning lessons could not be learned and families experienced repeated serious incidents and harm.
"There should never again be a review of this scale...Going forward, there can be no excuses"
The inquiry was ordered by Tory MP Jeremy Hunt in 2017 when he was health secretary.
He said on Wednesday the numbers were "worse" than he could have imagined and he hoped the report would be "a wake up call".
Ms Ockenden said: "Throughout our final report we have highlighted how failures in care were repeated from one incident to the next.
"For example, ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections resulted in many babies dying during birth or shortly after their birth.
"In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.
"The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved.
"There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths.
"What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies.
"This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding."
Ms Ockenden's team of investigators found families were locked out of reviews when things went wrong and were often treated without compassion and kindness.
In an interim report published in December 2020, Ms Ockenden noted that for around 20 years the Caesarean section rate at the trust was consistently 8% to 12% below the England average, with this being held up locally and nationally as a good thing.
Her review team formed the clear impression there was a "culture" within the trust to keep Caesarean section rates low - perceived as the "essence" of good maternity care in the unit.
"I feel proud on behalf of my daughter's legacy"
Richard Stanton and Rhiannon Davies, who have campaigned for years over the poor care, lost their daughter Kate hours after her birth in March 2009. The couple have been the driving force behind the campaign for answers following Kate's death.
The trust noted the death but described it as a "no harm" event, although an inquest jury later ruled Kate's death could have been avoided. The trust still insisted its care had been in line with national guidelines.
You can watch her full interview with us here;
In an interview with us, Rhiannon said: "It's been a very long fight to get to this point. And I'm confident there will be a lot of actionable learning that will come from this report that will create significant, positive change.
"I feel I have done this for Kate, and then for all of the other families who have been affected, who could hopefully have their outcomes improved. So I would say I feel proud on behalf of my daughter's legacy.
It's been a really healing process to let go a little bit of having to hold all of the facts, all of the data, all of the concern, trying to drive it forward and trying to raise awareness. It's been really quite healing to be able to let go and entrust Donna, and her team have earned the families trust."
Another couple who have led the campaign for safer care are Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016 from a Group B Strep infection. A year later, a coroner ruled her death could have been avoided.
A criminal investigation into what happened at the trust is being carried out by West Mercia Police. The force released this statement ahead of the report's publication;
Changes and improvements going forward
Ms Ockenden identified 9 areas and 60 actions for learning and improvement at the trust, including;
- Management of patient safety
- Patient and family involvement in care and investigations
- Complaints processes
- Staffing
In addition, 15 "immediate and essential actions" for all maternity services in England are put forward, covering 10 key areas, including that NHS England must commit to a long-term investment plan to ensure the "provision of a well-staffed workforce".
The report added that appropriate, minimum staffing levels must be agreed nationally and locally, and adhered to, while there should be a clear escalation policy when staffing levels are not met.
Furthermore, every trust should also have a patient safety specialist for maternity services, while "meaningful" incident investigations should happen, with proof of learning six months later.
Other actions include all trusts should offer bereavement services seven days a week.
NHS England's committed £127million for maternity services but the report said this is "still significantly short" of the £200-£350million recommended by MPs in 2021.
Ms Ockenden said: "A death of a mother or baby, or a birth incident which results in an injury should never be ignored.
"There should never again be a review of this scale, in both numbers, and the length of years across which these concerns remained hidden."
Shrewsbury and Telford NHS Trust statement
Government statement
Health and Social Care Secretary Sajid Javid said:
“Donna Ockenden’s report paints a tragic and harrowing picture of repeated failures in care over two decades, and I am deeply sorry to all the families who have suffered so greatly.
“Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.
“I would like to thank Donna Ockenden and her whole team for their work throughout this long and distressing inquiry, as well as all the families who came forward to tell their stories.”
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