This week saw the publication of the Ockenden Report, a landmark investigation into the NHS’s worst ever maternity scandal.

The report by senior midwife Donna Ockenden comes after a five-year investigation into the maternity care at Shrewsbury and Telford NHS Trust, investigating 1,862 cases, mostly between 2000 and 2019.

Substantiating the Trust’s devastating failings, yesterday’s report confirmed that mothers and babies had died avoidably over the two decades.

According to the BBC, the report found that nine mothers and 201 babies “could have survived” if better maternity care had been provided. 131 of those were stillbirths and the other 70 were “neonatal deaths”.

The report went on to conclude that even more babies had suffered serious injuries from poor care over that time. These included fractured skulls, broken bones and life-changing brain injuries. Many of these were a result of traumatic births and mothers being denied Caesarean sections.

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The scale of the scandal was far “worse” than expected, with former health secretary Jeremy Hunt ordering the inquiry back in 2017 when there were originally 23 cases of concern.

“Our team of independent experts examined the maternity care provided to 1,486 families over two decades at the Trust,” Ockenden announced in a statement as the report was published. “We found that the Trust repeatedly failed to learn from clinical incidents and failed to listen to families across the years.

“We also found that the Trust’s own governance procedures failed to hold the maternity service to account and that external bodies failed to monitor the care provided effectively. We have identified more than 60 Local Actions for Learning for the Trust. And another 15 key Immediate and Essential Actions to improve all maternity services in England including financing a safe maternity workforce and ensuring trust Boards have oversight of maternity departments, listen to families and staff.”

Ockenden went on to explain that a lot of the Shrewsbury and Telford Hospital NHS Trust failings were “not unique”, outlining essential action and calling for systemic change.

Ockenden went on to state that women in England would not be safe in childbirth until the recommendations of her report were implemented in full.

“Tributes must be paid to the families who have contributed to this review,” Ockenden’s statement concluded. “Without their voices this endeavour would not have taken place and their experiences have been central to identifying the actions that must be taken forward at this Trust and all maternity services.”

Read the Ockenden report in full.

We will continue to update this story.

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