The final report by Senior Midwife Donna Ockenden follows her independent review into the maternity care at Shrewsbury and Telford Hospital NHS Trust. The report has found catastrophic failures that may have contributed to the death of over 200 babies, 9 mothers and caused life-changing injuries to many others.


This review of maternity services is considered to have been one of the largest in NHS history. Initially the review was to consider 23 families’ cases of alleged failures; but this number grew to nearly 1,500 families. The review began in 2018 following two families’ campaign for change after losing their baby daughters.


The review considered many aspects of clinical care in maternity units including:

  • Antenatal
  • Intrapartum
  • Postnatal
  • Obstetric anaesthesia
  • Neonatal care


The report highlights a culture of mistakes not being investigated; parents’ concerns being ignored; and a failure on the Trust to learn from mistakes leading to repeated and almost identical failures.


Key findings

The review found that 201 babies could have survived had the hospitals provided better care. In addition, there were 29 cases of babies suffering severe brain injuries and 65 incidents of cerebral palsy. Ms Ockenden said failures in care “…resulted in tragedies and life-changing incidents for so many of our families.”

The Report found examples of: ineffective monitoring of foetal growth; a culture of reluctance to perform Caesarean sections; a culture of fear and anxiety in staff to speak out over concerns for safety and care.

It is clear from the Report that a dangerous culture exists of mistakes not being investigated or open to external scrutiny. Furthermore, in cases which were investigated, there was a lack of transparency and honesty.


The reasons for these failures

Ms Ockenden found the reasons for theses failures were clear: not enough staff, a lack of ongoing training and effective investigation and a culture of failing to listen to the families or concerned staff involved.

In hundreds of instances the Hospitals failed to appropriately investigate deaths or conduct serious incident investigations meaning repeated mistakes were made with catastrophic outcomes for the families involved. The failures in care at the maternity unit were not one off or isolated incidents of negligence and represent an institutional failure in care.


The future of maternity care

The review presents a number of specific improvements of care across all maternity disciplines. Ms Ockenden states that, there could be “no excuses” going forward.

It has been recognised that these failures in care are not unique to Shrewsbury and Telford Hospital Trust and lessons need to be learnt in maternity care in many other areas.

There is a need for significant investment in maternity care for improving workforce, training, investigation, and accountability measures. Since publication of the interim report in December 2020 it would appear there has been continuing progress in recruitment and retention of maternity staff, including both midwives and obstetricians.

The Report aim is to highlight failures, encourage learning from mistakes and recommends improvements to ensure delivery of safe and compassionate maternity care locally and across England. The Government has made a commitment to halve the rates of stillbirths, neonatal and maternal deaths, and brain injuries in babies suffered at birth or soon after, which were seen in 2010 by 2025.


Link to the Report: Final report of the Ockenden review – GOV.UK (

If you or someone you know has been affected by any issues in this report; or believe you have received negligent treatment, then please contact us on 01253 778231 to speak with a member of the Medical Negligence Team.