The Ockenden Maternity Review – the scale of the tragedy revealed

The Ockenden Maternity Review, released on 30 March 2022 investigating maternity services at Shrewsbury and Telford Hospital NHS Trust, has now identified the scale of the worst maternity scandal in NHS history.

The Final Report finds that significant or major concerns over the care received at the hospital Trust has been linked to:

• At least 201 tragic baby deaths, either resulting from stillbirth or death in their neonatal period.
• At least 94 children being starved of oxygen during their birth, leading them to have suffered a hypoxic brain injury or HIE and cerebral palsy.
• 9 mothers dying as a result of the poor maternity care that they received.

The report identifies the underlying root causes for these heart-breaking and life changing events as:

• Ineffective monitoring of babies’ growth during their mother’s pregnancy.
• A culture of reluctance to perform caesarean sections even when the mother requested one or there was a clinical need. The hospital Trust’s statistics on caesarean sections against national averages have previously been released which showed that they consistently had between 8-12% lower than average rates.
• Failures by national bodies to challenge and investigate hospital Trust failures and shortcomings.
• Failures within the hospital Trust itself to conduct appropriate serious untoward investigations when incidents occurred and listen to families’ concerns. Even blaming mothers for their own baby’s death.
• Staff shortages.
• Lack of ongoing training.

In light of the failures identified, the report sets out “a blueprint” for safe maternity care to learn from the tragedies that happened at Shrewsbury and Telford Hospital NHS Trust, and to prevent similar failings in care.

The “four key pillars” are:

1. Safe staffing levels.
2. Ongoing and continuous training leading to a well-trained workforce.
3. Learning lessons from incidents.
4. Listening to families at the heart of these tragic events.

The Final Report follows the announcement on 25 March 2022 from the government that they are committed to spending £127 million on maternity services to help ensure safer and more personalised care for women and their babies. However, as the Final Report highlights, this is still significantly short of the £200 – £350million investment recommended by the Health and Social Care Select Committee in June 2021 to help tackle the root of the failings in maternity care.

Kay Taylor, a Partner specialising in obstetric claims at CL Medilaw commented:

“The scale of the tragedy uncovered at Shrewsbury and Telford Hospital NHS Trust is unprecedented, but many of the underlying causes are a repeat of those failings identified in previous maternity inquiries. To ensure this amounts to a turning point in maternity care, there must be a commitment to implementing the recommendations of the Ockenden report calling an end to other mothers and babies suffering from the same poor care and  heart breaking outcomes. Having helped many families who have been harmed by the same failings throughout England and Wales, we hope that this report brings about the long overdue changes needed to ensure safe outcomes within maternity care.”

If you have concerns in relation to the care you or your child received at Shrewsbury and Telford Hospital NHS Trust or at any other hospital across the country, please contact us for a free review of your claim.

Kay Taylor | Partner Laura Cook | Partner Charlotte Moore | Partner