The Ockenden Review: urgent action needed to prevent further baby deaths

An investigation has found that blame was put on mothers for the death of their babies’ and that a number of women died in labour due to negligence at a maternity unit in England.

The review – chaired by senior midwife Donna Ockenden – was first launched in 2017 after a number of baby deaths occurred at Shrewsbury and Telford Hospital NHS (SaTH) Trust.

Initially, the inquiry was looking into 23 cases of maternity care between 2009 and 2016, before this number rose to 40 and then 100 cases between 1998 and 2017. The investigation has now expanded considerably with nearly 2,000 families having been contacted to investigate their experience of the maternity services at the trust.

There have been a number of worrying themes emerge from the review so far and as such it was deemed necessary to publish an urgent report to share with all providers of NHS maternity services.

Whilst there are a number of common themes that resonate with cases that Ashtons Legal have managed over many decades of birth injury and stillbirth cases, for example: inadequate assessment of risk, poor management of high risk pregnancies, escalation of concerns during labour and inadequate monitoring of fetal wellbeing, there was an overall sad trend of lack of care and compassion from maternity staff at this trust.

Speaking on behalf of many families that Ashtons have represented over the years, parents often blame themselves when a tragic incident occurs. They often feel as though there was something they could have done differently to avoid such an outcome. Many carry that sense of guilt forward when adjusting their lives to either life without their baby or having to deal with a child with significant mental and physical disabilities that are life changing for all involved.

It is desperately sad that so many parents contacted as part of the investigation felt as though they had been dismissed by the trust or that their concerns were not at all listened to. With no ability to change the outcome of their own situation, I have found that in these scenarios, parents often become passionate about highlighting issues so that essential changes can be made in order to spare anyone else from experiencing the heartache they have felt.

There is a lot of fantastic work that is carried out by our maternity services every day, however unless, and until, we can truly adopt a culture of learning from mistakes and putting patient safety at the top of the agenda, there is a missed opportunity to reduce the incidence of such tragedies.

If you or a loved one has questions about maternity care that has been received, or if you have been affected by the issues raised in this review, please feel free to get in touch with us and we will be happy to help you in any way that we can.

Click here if you would like to read the full report. A final review into all 1,862 cases will be published next year.