31 Mar 2022

Clinical Negligence

What can be learned from the Ockenden Report’s devastating findings?

As the long-awaited final report into maternity services at the Shrewsbury and Telford Hospital NHS Trust was published yesterday, Sara Haf Uren, Partner in our Clinical Negligence Team, discusses the review’s distressing findings.

In 2017, Secretary of State for Health and Social Care, Jeremy Hunt MP, commissioned an independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust. The result was an examination of the maternity care and treatment provided to 1,486 families at the Trust between 2000 and 2019. It has been labelled the largest maternity scandal to be uncovered in the UK.

The report does not make for comfortable reading but has provided much-needed answers to those families who were at the heart of the substandard care delivered.

The report identifies 60 local actions for learning for the Trust including:

  1. Improving management of patient safety
  2. Patient and family involvement in care and investigations
  3. Improving complaints management
  4. Care of vulnerable and high risk women
  5. Diabetes care
  6. Multidisciplinary working
  7. Midwifery-led units and out-of-hospital births
  8. Staffing, including anaesthetic staffing
  9. Communication with GPs.

Sadly, the report uncovered that there were 210 preventable deaths, 201 of them babies and of that number, 131 were stillborn. Further, it explained that there was a refusal to follow national guidelines, reluctance to perform caesarean sections which resulted in many avoidable injuries and deaths, inability to learn and a culture of cover-up.

In addition, there were 15 immediate and essential actions for all maternity services in England covering ten areas including:

  1. Essential action on training
  2. Meaningful investigations with family and staff engagement and practice changes introduced in a timely manner
  3. Mandatory joint learning across all care settings when a mother dies
  4. Care of bereaved families.


Of the failures identified, Chair of the review, Donna Ockenden, Senior Midwife stated:

“The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved. There was a tendency of the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths.

“Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require.”

“The legacy of this review should be a maternity service across England that is appropriately funded, well-staffed, trained, motivated and compassionate and willing to learn from failings in care.”

The damning report will no doubt be an opportunity for many other Trusts and Health Boards across both England and Wales to reflect on their standards of maternity care.

Sadly, this has not been the only maternal negligence scandal that has gained press attention recently. In October 2021 the Maternity Services Oversight Panel (IMSOP) prepared a report of the findings from a review of stillbirths at the former Cwm Taf University Health Board between 2016 and 2018 and another in January 2022 following an independent review of the neonatal services provided at Prince Charles Hospital. The panel ensures that recommendations from a review of maternity services at the former Cwm Taf UHB are implemented. You can find more information here.

We cannot imagine how distressing it must be for the families involved in this scandal to have to relive these devastating events. We just hope that today’s report will bring them some small degree of comfort that changes are now being implemented to ensure others do not have endure a similar experience. Hopefully these shocking failings will encourage the development of a safer, more open approach to maternal health and care in Wales and England.

Here at Harding Evans, we work with many families who have experienced devastating loss or life-changing injuries due to maternal negligence. While we sadly cannot change the actions or circumstances that resulted in these tragedies, we can work with families who have been affected to ensure that others do not have endure a similar experience.

By instructing us to pursue a claim of negligence, those families’ stories will encourage the development of a safer, more open approach to maternal health and care in Wales and England.

You can find further details on the range of maternal and fetal cases we cover here.

If you have been affected by maternal negligence and would like to discuss your story, then please contact Sara Haf Uren, Partner in our Clinical Negligence team for a free initial meeting. You can call Sara on 01633 760692 or email shu@hevans.com.

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