Ockenden report: 10 things you need to know about the maternity scandal

201 babies and nine mothers ‘could have survived’ UK’s biggest maternity scandal Credit: PA images

The Ockenden report found a string of "repeated failures" spanning a period of 20 years - including at least 304 cases where there was avoidable harm.

As a result of these failures, babies died or were left seriously disabled owing to catastrophic mistakes at the Shrewsbury and Telford Hospital NHS Trust.

Rhiannon Davies and Richard Stanton with a copy of the Ockenden report at the Shrewsbury and Telford Hospital NHS Trust Credit: PA

Here's what else we've learned.

How many cases were examined?

The major review into the trust, led by senior midwife Donna Ockenden, has examined 1,486 cases between 2000 to 2019 - making it the largest inquiry into a single service in the history of the NHS.

What were some of the failures?

  • At least 201 baby deaths where there are significant or major concerns over their care.

  • At least 94 brain injuries to babies where there are significant or major concerns over their care, and 9 maternal deaths.

  • 40% of still births reviewed did not have a trust investigation.

  • 1,393 of the cases happened between 2000 and 2019 and 18 incidents are from post 2019.

Why has the review taken so long to be released?

The interim Ockenden Report, covering the first 250 cases, was released in December 2020.

That review was delayed by a by-election in North Shropshire, and by the discovery of piles of new evidence by the Trust in the autumn.

The report published on Wednesday, 30 March was delayed earlier this month due to a statement made in the House of Commons by patient safety minister Maria Caulfield regarding an indemnity policy, which she said was needed in case anybody launches legal action as a result of the final report or the process of compiling it.

This began a 14-day ‘freeze’ period where publication is paused while MPs are allowed to raise objections.

How many incidents could have been prevented?

The report found at least 304 cases where there was avoidable harm.

Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

Overall, 12 deaths of mothers were investigated, none of whom received care in line with best practice at the time. In three-quarters of these cases, care “could have been significantly improved”.

The report noted that internal reviews of the deaths were poor, with some women blamed for their own deaths.

What's the reaction of health leaders?

The chief executive of the trust, Louise Barnett, said improvements had been made and were continuing, saying: “Today’s report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust.”

Sajid Javid, the Health secretary has apologised to bereaved families, saying: "The trust failed to investigate, failed to learn and failed to improve... to all the families that have suffered so greatly, I am sorry."

Who's been leading the review?

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

Between 2006 and 2014 she was the Chair of the England Royal College of Midwives (RCM).

Why did the report happen?

The report would never have happened without concerns being raised and highlighted by two incredibly brave families.

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

The two mothers didn’t know each other, but Kayleigh had read about Rhiannon’s battle for answers in the local paper and quickly found similarities in both their stories, and decided to investigate.

Through determination they discovered the names of 23 babies, and a pattern of mistakes being made.

It convinced the then-Health Secretary Jeremy Hunt to order the review and led to hundreds more families coming forward to speak about their own experiences.

How have families reacted?

Julie Rowlings' daughter Olivia died after 23 hours of labour following a consultant’s use of forceps.

She said: “I would like somebody from the trust to sit face to face with me, and talk to me. They’ve never done that.

“They’ve apologised, via media, they’ve apologised to all the families via media, but they’ve never sat down with the families.

Julie and Neil Rowlings read the Ockenden report Credit: PA

“I want them to apologise face to face for what they put us through.

“I’d like them to apologise for ignoring what we were trying to tell them at the time. It would go a long way.”

Staff speak out about 'bullying culture' in the report

A questionnaire called 'staff voices' was offered to past and present staff at the trust, with the aim of highlighting where improvements are needed and to report on good practice.

65% of those surveyed said they'd either witnessed been the target of bullying.

Some staff say they'd already been discouraged by managers at the trust to take part.

A big theme that emerged was a culture of bullying and fear among some staff to report and escalate incidents within maternity care.

What happens next?

The Ockenden report has raised 15 areas for “immediate and essential action” to improve care and safety in maternity services across England.

Areas like safe staffing, escalation and accountability, clinical governance and robust support for families have all been included as “must dos”.

The trust has also been handed 60 local actions for learning, in light of care received by 1,486 families.

Louise Barnett, the chief executive at the trust said the Ockenden report would be used to guide future actions:

“We will be focusing on all the areas that have been set out so that we can ensure that our plans are fully comprehensive,” she said.

“We will continue to build on the progress we have made from the first report to deliver high quality care.

Louise Barnett, Chief Executive at the trust Credit: PA

“I believe our services are safe.

“We have made significant investment in our services, we’ve recruited more midwives and consultants, we’ve invested very heavily in training…  and also we’ve been very open and transparent about the work we do.”

Support and advice available for parents and families: