The Ockenden review - a watershed moment in maternity care?

We explore the key findings, recommendations and lessons learned following the largest review into maternity services at an individual NHS Trust.


Following complaints of poor maternity care at Shrewsbury and Telford Hospitals NHS Trust (SaTH), the government commissioned an independent review, chaired by Donna Ockenden, a senior midwife. The inquiry scrutinised maternity care provided to 1,486 families, largely between 2000 and 2019.

Within the recently published final report of the review – Findings, Conclusions and Essential Actions from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust - it was concluded that SaTH failed to investigate, learn and improve from repeated incidents of poor care. The report identifies themes in both the care and investigations procedures at SaTH. Sadly it was concluded: 

  • Cerebral palsy and hypoxic ischaemic encephalopathy (HIE): “significant and major concerns” were raised over the maternity care provided to over 40% of babies who had suffered brain injuries, and that appropriate care may or would have led to a different outcome. In cases of HIE, a form of newborn brain injury caused by oxygen deprivation, there were "significant and major concerns” over the care provided in two-thirds of cases.
  • Stillbirth: one in four cases were found to have “significant or major concerns” over the care provided, and that appropriate care may or would have led to a different outcome.
  • Maternal deaths: in nine out of twelve cases of maternal deaths reviewed, it was concluded that the care could have been significantly improved.
  • Neonatal deaths: “significant or major concerns in the maternity care which might or would have resulted in a different outcome” were highlighted in nearly a third of all incidents reviewed.

The review highlights that previous internal and external investigations into clinical incidents within maternity services at SaTH did not lead to changes in practice or learning, with missed opportunities for intervention to provide safer maternity care.

Staff interviews obtained as part of the review suggest there was a preference amongst some clinicians for vaginal birth and a reluctance to proceed to Caesarean section. Previously, Trusts have been monitored on Caesarean section rates. Since 15 February 2022, Trusts have been told to stop monitoring Caesarean section rates against a previous target of around 20% of births to be by Caesarean section. This is no longer seen as an appropriate metric by which to judge the performance of maternity services. The review acknowledges that lower than average Caesarean section rates at SaTH led to some mothers being harmed.

Recommendations – essential actions

The report recommends 15 immediate and essential actions (IEA’s) that all maternity units across England should implement, if not already in place. These include measures relating to:

  • Staffing: escalation and mitigation policies where maternity staffing levels fall below minimum staffing levels. The report stresses the importance of workforce funding and planning to ensure that maternity units are safely staffed with the right mix of staff.
  • Training: regular and mandatory training for staff who work together.
  • Funding: it is recommended that the budget for maternity services be increased immediately from £200 millionm to £350 million per year, with funding ringfenced for training.
  • Governance: trust boards must be aware of and manage the safety and quality of care provided by their maternity units.
  • Incident and complaints investigations: “incident investigations must be meaningful for families and staff and lessons must be learned and implemented into practice in a timely manner”. Specifically, “change in practice arising from an SI investigation must be seen within six months after an incident occurred.” Complaints themes and trends must be monitored.
  • Learning from maternal deaths: all maternal post-mortems to be performed by pathologists experienced in maternal physiology and pregnancy related pathologies.
  • Complex antenatal care: women must have access to appropriate pre-conception care for conditions such as diabetes, hypertension, epilepsy and cardiac disease and “Trusts must provide services for women with multiple pregnancy in line with national guidance”. Systems must be in place for women at risk of preterm birth.
  • Labour and birth: women who choose birth outside a hospital setting must receive accurate advice as to transfer times to obstetrics units. The report adds that “centralised CTG monitoring systems should be mandatory in obstetric units” alongside clear pathways for the provision of neonatal care. All unwell postnatal women should have a timely consultant review with anaesthetic follow up for any anaesthesia complications.
  • Bereavement care and supporting families: “trusts must ensure that women who have suffered pregnancy loss have access to appropriate bereavement services”. The wellbeing of mothers and their families must be at the heart of all aspects of maternity service provision, to include clear pathways for psychological support.


The Ockenden report is published against a background of increasing scrutiny of obstetric claims. Such cases represented 11% of all clinical negligence claims reported in 2020/21 but 59% of the value of likely compensation payments*, largely due to the high future costs of caring for babies who suffer a serious brain injury during birth. Beyond the financial cost there is undoubtedly a very real human cost to the families and staff involved in these often distressing claims.

The Ockenden report is essential reading for those involved in the provision of safe maternity care. We recommend that Trusts review their maternity and investigation procedures and policies against the 15 IEA’s. Trust boards must understand and monitor the safety of their maternity units.

When things do go wrong, the report emphasises the importance of a full and impartial investigation and the duty of candour. When an incident does occur, it is essential that support is provided to both the families and clinicians involved.

*NHS Resolution annual report and accounts 2020/21

Read other items in Healthcare Brief - May 2022

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