Ockenden Report: inadequate investigations into deaths of mothers and babies and a culture of silence

5 April 2022

Last week the Ockenden report was finally published. A team of Midwives and Doctors, headed by Midwife, Donna Ockenden reviewed the maternity care given to 1,148 families between 2000 – 2019. The report made for shocking reading.

The media widely reported the findings, that repeated failures at Shrewsbury and Telford NHS Trust lead to the deaths of 201 babies and 9 mothers who could otherwise have been saved, leaving others with life changing injuries, such a brain damage caused by hypoxic ischaemic encephalopathy (HIE) and children later diagnosed with cerebral palsy.  

Of the HIE cases investigated, the report found that in 69.5% of cases there were significant and major concerns about the maternity care that was given. Had that care been appropriate, the outcome for those babies, and by extension, their families, might well have been different.   

The report finds that there was a toxic workplace culture at Shrewsbury and Telford NHS Trust, an over-confidence in staff of their ability to manage complex pregnancies and a strong preference for vaginal birth over caesarean sections. Indeed, the Trust’s low rate of caesarean section birth was held up as a national example.

Sadly, the Trust failed to learn from its own investigations, which the report found were often inadequate and did not identify systemic and service wide failings to follow appropriate procedures and national guidelines. This meant that there were many lost opportunities to learn and make improvements to the care given to women and their babies.

The report rightly identifies that the NHS staff who have worked throughout the pandemic are exhausted. It pushes for the budget for maternity services to be increased by £200 - £350 million a year with immediate effect and points out that more needs to be done around workforce planning in terms of recruiting and retaining both obstetricians and midwives.

We hear often from clients that one of their main reasons for investigating a claim is to avoid the same thing happening to anyone else. Sadly, it seems that a culture of silence persists at the Trust, with the report describing how many staff members withdrew their cooperation with the investigation in the final weeks before publication out of fear of being identified. Kingsley Napley have long campaigned for the Duty of Candour, and for a culture of openness as being the only way to ensure that mistakes are not repeated. 


If you would like any further information or advice about the topic discussed in this blog, please contact Kirsty Allen or our Medical Negligence and Personal Injury team.



Kirsty Allen has a varied caseload of medical negligence and personal injury matters. Her medical negligence work includes child cerebral palsy and adult brain injury cases, as well as fatal claims (including inquests), loss of sight cases, as well as failure to diagnose cancer and gynaecological claims.


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