Ockenden: catastrophic failures of governance at Shrewsbury and Telford led to tragedy in maternity care

07 April 2022

In her final report, Donna Ockenden’s team concluded that catastrophic failings over nearly 20 years in maternity care at Shrewsbury and Telford Hospital NHS Trust led to nearly 300 avoidable baby deaths or babies being brain damaged.

Several mothers died while others were made to have ‘natural’ births (although in many instances this was accelerated using synthetic oxytocin) despite the fact they should have been offered a Caesarean section.

After reading the report, Kashmir Uppal, clinical negligence specialist partner, who represents several families in the long running NHS inquiry into failings at the Trust, suggests the key factors in such an appalling level of care were the Trusts’ drive for ‘normal birth’ and systematic, repeated, failings in governance. This compromised safety and caused the devastating deaths of hundreds of babies. She says:

“The report showed failures in governance, management and care that were repeated from one incident to the next and babies being harmed due to ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections. Indeed, Donna Ockenden herself states in the report that the delivery of safe and compassionate maternity care locally and across England can only be achieved through a workforce who is well managed and trained, which was clearly not the case at Shrewsbury and Telford.”

Unprecedented in its size and scale, the final Ockenden Report found that in hundreds of cases, where there is poor outcome, there was a failure to undertake serious incident investigations (even cases of death were not examined appropriately) and where investigations did take place, families were locked out of inquiries into what happened, were treated without compassion and kindness and were often wrongly blamed for the death of their baby. These combined failings led to missed opportunities at the Trust, which is still currently ranked as inadequate by regulators.

Ockenden revealed that a total of 1,486 families were affected, however she also maintains that, after reviewing the experiences of so many families and listening carefully to past and present staff who came forward, the recommendations in the final report represent a once in a generation opportunity to improve the safety and quality of maternity service provision for families across England – if those recommendations are quickly acted upon.

The report identified no less than 60 actions for learning at the trust and 15 immediate actions which must be implemented by all NHS Trusts in England that provide maternity care to ensure safe staffing, robust support for families and improved postnatal care. They include:

  • Staff must be able to escalate concerns.
  • Incident investigations must be meaningful for families and staff and lessons must be learned and implemented in practice in a timely manner.
  • Staff who work together must train together.
  • Women who choose birth outside a hospital setting must receive accurate advice with regards to transfer times to an obstetric unit should this be necessary.
  • Trusts must ensure that women who have suffered pregnancy loss have appropriate. bereavement care services.
  • Care and consideration of the mental health and wellbeing of mothers, their partners and the family as a whole must be integral to all aspects of maternity service provision.

Kashmir highlights point 12 in the report, which studied 498 cases of stillbirth, and the finding that 1 in 4 had significant or major concerns in maternity care which if managed appropriately might or would have resulted in a different outcome. This is particularly resonant for Shoosmiths client, Kamaljit Uppal. Whilst Kamaljit’s son Manpreet was not stillborn, he died shortly after his birth in 2003. If the Trust had managed the birth appropriately, Kamaljit would not have suffered this e tragic. Kashmir comments:

“Kamaljit asked for a Caesarean section on more than one occasion as she was worried about the safety of a vaginal delivery as Manpreet was a footling breach, but her requests were simply dismissed. The conclusions published today in the Ockenden report would seem to support our view that that this was because the trust had a policy of ‘normal births’ at all costs.”

Kashmir also notes the failures in governance and leadership cited in the report, which said that Trust leadershipup to board level was in constant churn and change and that management failed to foster a positive environment to support and encourage service improvement. The report found that investigatory processes were not followed to a standard that would have been expected, reviews were cursory and not involving MDT (multidisciplinary teams) and did not identify the underlying systemic failings and significant areas of concern.

Perhaps the most damning verdict on failures in oversight and governance is contained the report’s introduction, where Donna Ockenden states that: "What is astounding is that for more than two decades these issues have not been challenged internally and the Trust was not held to account by external bodies.”

Kashmir is concerned that no external body picked up on the data and statistics coming out of the Trust, such as the number of baby and maternal deaths compared to the national average. Surely an external regulator should have recognised that the rates were higher and the corresponding lower than average caesarean section rates, should have raised some level of alarm, sufficient to warrant an external investigation?

There is little point in having external regulators if they either fail to examine the data or fail to properly analyse it.

Kashmir concludes:

“The report highlights that systemic change is needed locally, and nationally, to ensure that maternity care is always professional and compassionate. It is inevitable that mistakes will occur, but the failure to learn from those mistakes is such a missed opportunity. Going forward, there can be no excuses. Trust boards must be held accountable for the maternity care they provide. Mothers must be listened to, and families must be involved in any investigative process. It is only when there is learning and change that patient safety, which is in the interests of the patient and the NHS, will improve, but those lessons learned must be implemented in a timely way to prevent further tragedies.”


Additional media coverage

ITV News | Ockenden report 2022: Three mums whose lives were changed forever by NHS maternity scandal



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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