Ockenden Report Published 30 March 2022

Donna Ockenden reviewing Ockenden Report Findings
BSC, LLB (Hons) & LPC Sophia Azam
Legally reviewed by: BSC, LLB (Hons) & LPC Sophia Azam In: Medical Negligence

The long-awaited Ockenden report was published yesterday on 30 March 2022. The five-year inquiry was investigating serious maternity care failures at Shrewsbury and Telford Hospital NHS Trust.

Donna Ockenden, Senior midwife-led a review team that consisted of Obstetricians, midwives, neonatologists, paediatricians and a host of other experts, 90 in total.

Donna Ockenden stated that,

“the impact or serious health complications suffered as a result of maternity care cannot be underestimated. The impact on the lives of families and loved ones is profound and permanent”

In December 2020 an interim report was published the findings summarised in our previous article dated 28 March 2022.

The original 23 families investigated expanded to 1,486 families between 2000 and 2019. The report involves not just the families but also members of staff.

The report notes that whilst the findings arise from Shrewsbury and Telford Hospital Trust have resulted in the expanded immediate and essential actions, similar issues may occur in other trusts and the actions must be widely implemented in all maternity services. These actions will involve significant financial investment.  It is vitally important for there to be a culture change across the country.  

The final Ockenden report identified the following issues :


  • Substandard care of vulnerable women.
  • Failures to identify foetal growth restriction and some foetal abnormalities.
  • Poor management of multiple pregnancies.
  • Poor care for women with diabetes or hypertension.
  • A lack of obstetric ward rounds.
  • Failures to escalate concerns.
  • Delays in transferring women to the labour ward.
  • Misinterpretation of the antenatal cardiograph (CTG).

Intrapartum Care (Labour)

  • Failures to escalate concerns.
  • Lack of planned consultant reviews.
  • A lack of documentation by the labour ward coordinator.
  • There were 498 cases of stillbirth within the relevant period and it was sadly concluded that 25% of those cases with appropriate management, may have resulted in a different outcome.
  • High reliance on locum doctors.
  • Significant problems with the conduct of intermittent auscultation and interpretation of CTG traces and failure to recognise / escalate abnormal CTGs.
  • Inappropriate use of oxytocin.
  • Understaffed midwifery led units.
  • Poor management of the delivery of twins and high risk women.
  • Women and families have suffered psychological trauma deemed to be “harrowing and profound”.

Post Natal

  • Lack of consultant review.
  • Lack of post-natal observations.
  • Lack of escalation of abnormal findings to senior medical staff.
  • Lack of compassion and kindness.
  • Poor staffing levels.
  • Lack of sensitivity following bereavement.

Maternal Deaths

  • Of the 12 maternal deaths that were reviewed, in six cases, the reviewers found suboptimal care of the women and tragically, with different management, there might have been a different outcome.
  • The root cause analysis done did not involve all members of the team and all were investigated internally with external expert opinion sought apart from one case.

Obstetric Anaesthesia

  • Staffing was noncompliant with Guidelines for Obstetric Anaesthetists with insufficient sessions taking place.
  • Common obstetric conditions were not recognised or managed within established guidelines and there was a lack of documentation.
  • There was a low number of reported incidences between 2008 and 2021 which would indicate that staff accepted poor practice or that reporting incidences did not affect change.

The first Ockenden report that was published in December 2020 included evidence that concerns were not appropriately escalated leading to a direct impact on safety, 27 local actions were suggested. The second report highlights a failure to learn and a lack of progression at the Trust. After the second report, 64 local actions have been put forward for the Trust to consider and implement. They have not been included here but can be accessed using the link to the report below.

In the first Ockenden report seven immediate and essential actions (IEAs) were put forward. The second report includes 15 IEAs.

Immediate and Essential Actions Detailed in the Ockenden report

These include:

  • workforce planning and sustainability.
  • safe staffing.
  • escalation of concerns as necessary.
  • responsible clinical governance and leadership.
  • meaningful incident investigation.
  • multidisciplinary training.
  • Preconception care.
  • Improved management of preterm birth.
  • Improved out of hospital birth advice.
  • Outpatient obstetric follow up.
  • Improved postnatal care.
  • Improved bereavement care.
  • Clear pathways for neonatal care.
  • Family support.


The government has made £95.6 million available to investment in maternity services across England with a further £2.45 million allocated to the Royal College of Obstetricians to find the best ways of spotting early warnings signs of infants in distress. There is also an additional funding of £80 million for targeted development.  A further £4.5 million is allocated to increase the work force by recruiting midwives. The Health and Social Care report has stated that NHS maternity units need an investment of £200- £350 million to prevent women and babies dying or sustaining avoidable harm.

Donna Ockenden has stated in a letter to the Secretary of State dated 30 March 2022

“… this final report of the independent maternity review of maternity services at the Shrewsbury and Telford Hospital NHS Trust is about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives”

“The second report builds upon the first report in that all the LAfL and IEAs within that report remain important and must be progressed. For the second report my independent maternity review team have identified a number of new themes that we believe must be shared across all maternity services in England as a matter of urgency to bring about positive and essential change.”

Kate Barge from our Clinical Negligence Department has Commented:

For the courageous families concerned, their contribution to the report will mean that their voices are finally heard. They have created an ongoing legacy of safety for the future.

For the maternity services there will challenging times ahead. What is clear is that a significant culture change is required.  Compassion is required not just for patients but also between members of staff who need to communicate openly. Transparent incident reporting is required along with an ability to learn from past mistakes. With investment of time and resources and a willingness for staff to work together to achieve a shared vision, our maternity units will become safer places.

If you have any concerns about medical treatment that you or your baby have received please contact our team of specialist medical solicitors who are able to assist you on a no win no fee basis.

Contact Number 0800 999 2220

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