Ockenden inquiry: one year on from Shropshire hospitals maternity report
The inquiry investigated more than 1,500 cases at Shrewsbury and Telford Hospital NHS Trust.
Last updated 15th Apr 2024
A year on from the publication of a report into the biggest maternity scandal in NHS history, hospital bosses in Shropshire insist they are making "good progress" to improve services.
The inquiry, led by senior midwife Donna Ockenden, was set up following the deaths of more than 200 babies and nine mums at Shrewsbury and Telford NHS Trust over a 20 year period.
The report published in March 2022 said the Trust presided over catastrophic failings - 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.
What has changed?
The Ockenden report set out 210 actions the Shrewsbury and Telford Hospital NHS Trust should take in order to improve care and patient safety, as well as address issues around culture within the organisation.
A year on, Louise Barnett, Chief Executive Trust, told us: “Our valued colleagues in maternity services have been working hard to deliver all 210 actions from the first and final Ockenden Reports whilst also supporting the thousands of women each year who choose to have their babies at our Trust.
“Meaningful and sustainable change takes time, but I am pleased to say we are making good progress with 162 actions (77%) now delivered, putting us ahead of our delivery plan. We are working at pace to progress the outstanding actions, working with external parties where necessary change is outside our control.
"Alongside this, we are continuing with our wider improvement work and we’re listening to service users, using their feedback to inform our progress.
“We owe it to those who experienced poor care, and to those in our communities who are pregnant or considering parenthood, to deliver safe, compassionate and personalised care.
"We want women to feel confident about giving birth at SaTH and to be assured that supporting families to have the birthing experience they want is our absolute priority. We have further to go but we are determined to continue demonstrating real and effective change.”
How do families feel a year on?
Richard Stanton and Rhiannon Davies 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.
Reflecting on the last 12 months, Rhiannon Davies said she wasn't convinced that enough progress has been made to ensure the safety of mums and babies, and to address the culture within the Trust.
"An awful lot was said at the time when the report was published by many people in many different Trusts, by government, in this particular Trust but I do feel since then, there has been a real lack of momentum in terms of some of the most critical issues.
"There continues to be a problem in this country with clinicians who push for a so-called natural birth at any cost - to the detriment, to the harm of babies and mothers.
"Women are at their most vulnerable point when they're giving birth, and they are not in a position to question or to challenge. They have to trust that those around them have their best interests at heart, and that isn't always the case.
"Until that changes, voices like mine will still be there to push for change because it's not going to come from within."
Rhiannon added: "When things go wrong in maternity, it is literally life or death most of the time. It is that critical. And I just don't think there is enough momentum.
"If you think where Donna Ockenden is now, she's working with Nottingham families who have been through exactly the same set of appalling circumstances that the Shrewsbury and Telford families have been through. The numbers are astonishing and the cases are bang up to date, so not enough has been done yet."