What is the Ockenden report and how many baby deaths in Shropshire did it investigate?

An ambulance outside Royal Shrewsbury Hospital Credit: PA

A long-awaited report into the harm and deaths of mothers and babies at a Midlands hospital trust has now been published.

Senior midwife Donna Ockenden has examined cases involving 1,486 families affected by a maternity scandal at the Shrewsbury and Telford NHS Trust.

The Ockenden review was first launched back in 2017 and an interim report was published in December 2020, looking at the first 250 cases.

Families had been left frustrated by delays to the final report being released, which was due to be be made public at the end of last year.

The latest major review which probed a series of serious and deadly incidents in maternity care in Shropshire has now been published and found a string of "repeated failures" spanning 20 years.

They include:

  • failures to listen to families

  • failures to learn from clinical incidents

  • failures by multiple external bodies to act to improve maternity services at the trust over a period of two decades

It concluded that none of the mothers had received care in line with best practice at the time and in 75% of the cases the care could have been significantly improved.

What is the Shropshire maternity scandal?

The scandal dates back to 2009 and centres on the Shrewsbury and Telford NHS Trust hospital, focusing on medical practices at the Royal Shrewsbury Hospital and Princess Royal Hospital in Telford.

Rhiannon Davies and Richard Stanton lost their daughter Kate in 2009, after a series of failures in her care. Seven years later, Kayleigh and Colin Griffiths lost their daughter Pippa.

These two families were instrumental in lobbying ministers to look at the standard of care being offered by the Trust.

What is the Ockenden report?

The Okenden review was launched by then-Health Secretary Jeremy Hunt in 2017 on the basis of 23 deaths at the Shrewsbury and Telford NHS Trust.

Since then, it has ballooned to look at evidence from 1,486 families, making it one of the biggest health scandals in NHS history.

The inquiry looks at cases of death or harm between 1998 and 2017. This includes stillbirths, neonatal baby deaths, the deaths of mothers, babies born with disabilities due to alleged poor care, and alleged failures which led to serious ongoing injuries to mothers.

Last year, the first official report from the Ockenden review was published looking at the first 250 of those cases. It found babies’ skulls were fractured and medical staff at the trust blamed grieving mothers for the deaths of their children.

Today, the report found 498 cases of stillbirth were reviewed and graded - one in four cases were found to have significant or major concerns in maternity care, which if managed appropriately, might or would have, resulted in a different outcome.

It identified seven “immediate and essential actions” needed to improve maternity care in England and 27 local actions for learning.

It also found:

  • An “unacceptable” lack of kindness and compassion from some maternity staff

  • Families’ concerns about their care were dismissed or “not listened to at all”

  • Midwives failed to recognise when a pregnancy wasn’t progressing normally

  • Repeated failures to escalate problems to more senior staff

  • “Continuing errors” in monitoring babies’ heart beats

  • Inappropriate use of drugs, including oxytocin to speed up labour

  • A culture of reducing the number of Caesarean births without considering if it was causing harm

It also discovered that between 2013 and 2016, deaths in the maternity unit were 10% higher than in comparable hospital trusts.

The full and final Ockenden report has been published and our story on the review by clicking here.

Who wrote the Ockenden report?

The Ockenden report has been written by Donna Ockenden.

Who is Donna Ockenden?

Donna Ockenden giving evidence to the Commons Health and Social Care Select Committee Credit: House of Commons/PA Archive

Donna Ockenden is a senior midwife with more than 30 years experience of working within a variety of health settings both in the UK and internationally.

Ms Ockenden's career spans a number of sectors including acute providers, commissioning, hospital, community and education.

She was the Chair of the England Royal College of Midwives (RCM) between 2006 and  2014.

Why was the Ockenden report commissioned?

Richard Stanton and Rhiannon Davies have been campaigning for years, after their newborn daughter Kate died in 2009. Credit: Family handout

Rhiannon Davies and Richard Stanton lost their daughter Kate in 2009, after a series of failures in her care. Seven years later, Kayleigh and Colin Griffiths lost their daughter Pippa.

Between them, they compiled the initial list of 23 cases and lobbied Mr Hunt to investigate - and have campaigned determinedly for answers, not just for them, but for all families who have suffered harm. 

The review was launched on the basis of the cases of concern highlighted by the Stanton-Davies and Griffiths families.

What has Shrewsbury and Telford NHS Trust said?

Following the Ockenden report, Louise Barnett, chief executive at Shrewsbury and Telford Hospital NHS Trust, said improvements had been made and were continuing, adding: "Today’s report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust."

"We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.

"Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden report, and we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve."

Support and advice available for parents who have experienced child loss: