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The Ockenden Review: Major Failings in Maternity Care at Shrewsbury and Telford Hospital NHS Trust

The Ockenden Review, led by senior midwife Donna Ockenden, was published on 30 March 2022 detailing an extensive investigation into the maternity care provided by Shrewsbury and Telford Hospital NHS Trust (‘the Trust’). The anticipated release of the Review has been described as a “bittersweet day” by family members directly affected by the poor care provided by the Trust.

Commencing in 2017, the review into nearly 1,600 incidents at the Trust is the largest-ever inquiry into a single service in the history of the NHS. It includes an incident dating as far back as 1973, with the Ockenden team continuing to receive reports of further incidents as recent as 2021. Ms Ockenden has commented that “There should never again be a review of this scale, in both numbers and the length of years across which these concerns remained hidden”.

The Main Findings

The full Review sheds light on a devastating number of failings in the maternity care provided by the Trust. The key findings are as follows:

  • A review of 198 incidents involving stillbirths concluded that one in four had “significant or major concerns” about the maternity care that was provided. It further states that had the appropriate level of care been provided, a more positive outcome might, or would have, occurred.
  • Two fifths of the 198 stillbirths were not investigated by the Trust.
  • Only 43% of the reviewed neonatal deaths were investigated by the Trust, despite “significant or major concerns” raised about the care provided.
  • It was found that some women were blamed for their own deaths or for the injury or death of their babies.
  • There were “significant or major” concerns about a lack of care provided to two thirds of mothers where the baby was deprived of oxygen during birth. Consequently 23 babies were recorded as having suffered a severe brain injury; a further 65 cases involved cerebral palsy.
  • 12 cases involved the death of a mother where care “could have been significantly improved”.
  • A culture of unwillingness to perform caesarean sections was identified, even in cases where the procedure was essential to the welfare of both mother and baby; the rate of caesarean sections at the Trust was 8 – 12 % lower than the average in England. Staff felt pressured to keep caesarean rate as low as possible.
  • Interviews with several staff members revealed what one employee described as a “Republic of Maternity” at the Trust, with the department preferring to self-manage without input from the Trust.

In addition, it was recorded that the Trust failed to listen to families and to learn from mistakes. Despite a mounting number of cases over the last two decades, there has also been a clear omission by multiple external NHS bodies to take action.

Jacqueline Dunkley-Bent, the Chief Midwifery Officer, and Matthew Jolly, the National Clinical Director for Maternity and Women’s Health, have both acknowledged the severe failings of the Trust. £127 million in funding has been promised to improve leadership and the culture within the NHS, with efforts focussed on improving the maternity services provided.

Further, the Review has advised of 15 “immediate and essential actions” to be undertaken by all NHS Trusts to improve maternity services in England. These cover aspects such as workforce planning, multidisciplinary training and clinical governance, plus specific actions in relation to complex antenatal and postnatal care, neonatal care, bereavement care, preterm births, obstetric anaesthesia and supporting families.

The full Ockenden Review can be found at .

If you think that you may have a claim for clinical negligence, our Clinical Negligence Team would be pleased to speak with you. Details of how to contact us can be found at