The findings of the Ockenden Report Shrewsbury and Telford NHS Trust

The Ockenden Report’s findings released today are truly dreadful.

The report commissioned in 2017 investigated incidents of baby deaths, maternal deaths and avoidable harm to mothers and babies between 2000 and 2019, the result of which is shocking in the extreme.

At least 1,592 families suffered as a result of the Trust’s failures were contacted by Donna Ockenden and her enquiry team. Nine mothers died, 295 babies died! Although individual stories came to light during this entire period the extent of the systemic problems could never be imagined. The report identifies hundreds of avoidable mistakes, mostly surrounding a culture of fear from the staff and that the Trust favoured natural birth over caesareans, irrelevant of the situation. There was a reported lack of compassion from the staff. The families were left bereft and feeling they were to blame.

The report not only identifies the tragic errors, but also worryingly it highlights the significant issues facing maternity care as a result of a continued shortage of maternity care staff.
There are several immediate and essential actions required in the findings some of which are as follows:

• funding is a major issue
• maternity services must listen to women and families
• better and more cohesive training
• robust pathways for managing women with complex pregnancies
• risk assessments for women at each contact throughout their pregnancies
• dedicated lead midwife and lead obstetrician for all maternity services
• better broad oversight and training
• increase care of complex higher-risk pregnancies.

As a firm, we have serious concerns about lessons being learnt. Sadly these are not new issues. We have been conducting cases like these for decades. What concerns us greatly is that despite hearing about these cases and reports being made and investigations undertaken, they are still happening now. When we don’t learn from these mistakes the tragedies keep occurring. Far better delivery of feedback and transparency from insurers and Trusts to the whole of the NHS needs to occur. The report can never compensate those families affected by this catalogue of horrific errors and shocking culture of behaviour, but it does shine a light on changes that must be effected to avoid this from ever happening again. Our hearts go out to those families affected by this ongoing tragedy.