Ockenden Review: First Report Sets Out Key Themes and Learning Points for NHS Maternity Services

22 January 2021

The Ockenden review into maternity services at Shrewsbury and Telford NHS Trust (SaTH) last month published its first report setting out actions that need to be urgently implemented to ensure safe practice in maternity services at SaTH and across the NHS in England. When completed, the Ockenden review will likely be the largest clinical review of a single service in the history of the NHS.

Complications that arise at birth can have very serious and devastating consequences on families and loved ones. When those complications are the result of a poor level of care within maternity services it makes it even more painful.  If the opportunity to learn from incidents and improve maternity services is repeatedly missed, the damage is much worse. It is not just the families involved who are failed, but anyone who later uses a maternity service that is ultimately not as safe as it should be.

The review of maternity services at SaTH was first commissioned by the government in 2017, after concerns were raised by two sets of parents whose newborn daughters both tragically died. Rhiannon Davies and Richard Stanton lost their daughter Kate in 2009, and Kayleigh and Colin Griffiths’ daughter Pippa sadly died in 2016. 

Both sets of parents questioned the circumstances surrounding their daughters’ deaths and persisted in their calls for an independent review of the maternity care they had received.   In its first report, the Ockenden review has stated that both Kate and Pippa’s deaths were avoidable.

The review is being chaired by Donna Ockenden, an expert in midwifery care. Initially 23 cases of potentially substandard maternity care provided to babies and mothers were to be examined when the review started in 2017, but the numbers soon began to rise. When Kingsley Napley wrote an article regarding the inquiry in the summer of 2019, there were over 500 cases under review. The final number of maternity cases that will be reviewed now stands at 1,862.

These include cases of stillbirth, neonatal death, maternal death, hypoxic ischaemic encephalopathy (HIE) (grades 2 and 3) and other severe complications and poor outcomes for mothers and newborn babies which, very sadly, include death, cerebral palsy and other physical injuries. The cases being reviewed predominantly date from between 2000 to 2019, but earlier cases are also being looked at if the records are available.

Key Findings from the Initial Review of 250 Cases
Of the total 1,862 cases, the review has now looked at 250 cases.  Its first report describes emerging themes and findings, as well as learning points that must be acted upon at local Trust level and across the wider maternity system.

The findings relating specifically to the maternity service at SaTH have been split into various sub-headings in the report, which set out failings that include:

Compassion and kindness

Inappropriate language was sometimes used in cases of birth injury or death. Some women were blamed for their loss, further compounding their grief, or concerns raised by women and families regarding their care were not listened to at all. Kindness and compassion from medical staff was absent in many cases. 

Risk assessments for place of birth

Many cases showed little or no discussion of the most appropriate place of birth. Women and families were not explained what the risks were of  births at home or on midwifery-led units, nor what the transfer times were to obstetric-led units if complications did arise.

Management of women with complex pregnancies

  • Midwives’ clinical care and decision making often did not demonstrate the appropriate level of competence, including a failure to recognises deviations from a “normal” pregnancy and labour and escalate appropriately.
  • Poor consultant oversight of mothers with high-risk pregnancies, who remained under midwifery-led care or managed by obstetricians in training.
  • There were failures to spot pre-eclampsia, to treat high blood pressure and to escalate care to obstetric consultants, including one woman with large uterine fibroids where errors in interpretation of the baby’s growth were followed by premature delivery and, tragically, the baby’s death.

Escalation of concerns

An overarching theme was repeated failures by midwives and trainee doctors to escalate to senior staff for further review, which is a key part of safe practice. When some concerns were escalated they were not acted on appropriately.

Monitoring of fetal wellbeing and use of oxytocin

  • There were significant problems with fetal heart rate monitoring and the interpretation of CTG traces, which are used to monitor fetal heart rate.
  • There were many cases where oxytocin was used to induce labour when CTG concerns were present, which ought to mean that oxytocin use is reduced or discontinued. These types of cases were present throughout the period under review, which indicated a failure to learn from previous cases with poor outcomes.

Traumatic births

There were a number of cases with repeated attempts at forceps delivery, sometimes with excessive force, where babies sustained injuries including skull fractures and cerebral palsy. Many of these cases were not investigated by SaTH.

Numerous cases where vaginal delivery should not have been attempted or should have been abandoned for delivery by caesarean section.  There was also clear evidence that some obstetricians were not following guidelines for safe deliveries.

Caesarean section rates at SaTH

  • Despite the numbers of caesarean sections generally rising in the two decades covered by the review, the C-section rate at SaTH consistently remained below the average in England. Patients reported that they felt SaTH wished to keep caesarean section rates low and patients did not feel able to express a preference.  
  • There was a culture within SaTH to keep C-section rates low, as this was seen as the essence of good maternity care. There did not seem to be any consideration of whether this culture contributed to unnecessary harm.

Bereavement care

  • There was little evidence of follow-up bereavement care being provided to parents as it should. In several instances bereavement care was either inadequate or non-existent, which had a negative effect on parents’ wellbeing. 
  • Numerous families reported staff being dismissive, lacking compassion and that SaTH’s bereavement service either made contact too late or made things much worse.

Maternal deaths

  • There appeared to be a lack of antenatal multidisciplinary team (MDT) planning for women with pre-existing medical complications. Lead clinicians could not be identified in the majority of these cases.
  • There were often failures to recognise a deteriorating patient. High risk and significantly sick women were reviewed by junior medical staff without involvement of senior clinicians for long periods of time, leading to delayed escalation and transfers to high dependency or intensive care units.
  • Some cases of maternal death were not investigated by SaTH. Other cases were only investigated by a small governance team and cases were closed with no further actions identified, resulting in missed learning opportunities.

Poor obstetric anaesthesia practice and involvement of senior anaesthetists

  • There were several examples of a lack of involvement from the senior consultant anaesthetists on call, despite complex obstetric complications such as severe sepsis or pre-eclampsia.
  • There was limited consultant anaesthetist involvement in incident investigation and multidisciplinary team meetings after significant incidents.
  • In one case a woman’s CTG was discontinued for a significant time while an epidural was sited; when it was recommenced, an emergency C-section was indicated and the baby was born in poor condition.


From the 250 cases reviewed so far, the quality of neonatal care at SaTH for most babies appeared to have been satisfactory or good, and at times excellent. There were a small number of cases where the neonatal care was substandard, but these were very much the exception. So far there was no evidence of systemic poor practice in the neonatal service.


Learning and Action Points for SaTH
The interim report has outlined a number of actions points to assist SaTH in making immediate and significant improvements to its maternity service. Whilst too numerous to list them all in this article, they include:

  • a thorough risk assessment to be undertaken at every booking and antenatal appointment; 
  • Consultant Obstetricians to lead the management of complex pregnancies;
  • women to be provided with evidence-based information by all members of the maternity team so that they can make informed choices about their care; 
  • a Lead Midwife and Lead Obstetrician to be appointed at SaTH to ensure (amongst other things) that fetal monitoring is improved and that national guidelines on maternity care are adhered to;
  • SaTH must develop clear operating procedures for when junior obstetric staff and midwives should escalate care to the more senior consultant obstetricians;
  • Obstetric Anaesthetists must ensure they adhere to local national clinical guidelines. They must be completely integrated into the maternity multidisciplinary team and participate in team meetings and serious incident investigations.

Immediate and Essential Actions for Maternity Services Across England
The government expressly asked the Ockenden Review to also make recommendations in its first report on how to improve safety in maternity services across England. The interim report has set out these ‘Immediate and Essential Actions’ as:

  • All maternity services must appoint a dedicated Lead Midwife and Lead Obstetrician, both with demonstrated expertise to focus on and champion best practice in fetal monitoring.
  • Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway.
  • All Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.
  • Maternity services must ensure that women and their families are listened to with their voices heard.
  • Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks. Neighbouring Trusts must work collaboratively to ensure that local investigations into Serious Incidents have regional and Local Maternity System oversight.
  • There must be robust pathways in place for managing women with complex pregnancies.
  • Staff who work together must train together. Trusts must provide evidence of multidisciplinary training and working, including twice-daily consultant-led multidisciplinary ward rounds on the labour ward.
Many of these ‘Immediate and Essential Actions’ outlined in the first report are not new; they are largely developed from recommendations made in previous reviews and publications regarding maternity care across the NHS. The interim Ockenden report acknowledges that had previous recommendations from previous national maternity reviews, such as Northwick Park (2008) and Morecambe Bay (2015), been properly implemented at SaTH, some of the adverse outcomes now being investigated might not have occurred.

Future Improvements
When the Ockenden review is completed it will likely be the largest number of clinical reviews relating to a single service in the history of the NHS. Sadly, it has come too late for the women and families who have already lost babies and loved ones as a result of avoidable mistakes in maternity care at SaTH. The review however represents an opportunity to learn from past mistakes, which in turn will lead to better outcomes for babies and mothers in the future.

Encouragingly, Louise Barnett, SaTH’s chief executive, has committed to implementing all of the actions outlined in the interim report. The hope is the first report and the full review that follows will improve safety in maternity care not just at SaTH, but at all maternity services across England.

Further information 

Our team at Kingsley Napley has investigated many cases involving stillbirths, babies who pass away shortly after birth and those born with injuries as a result of childbirth.  If you would like some advice on your options and how we can help you, please contact our Medical Negligence & Personal Injury team – alternatively you can call us on 020 7814 1200, or by email at  claims@kingsleynapley.co.uk.



Punam Sood is a Senior Associate in the Clinical Negligence and Personal Injury Department. She deals with all aspects of medical negligence claims, including birth injury and acquired brain injury claims, claims relating to fatal accidents, those involving gynaecological injuries following childbirth and those due to the delayed diagnosis of cancer.   


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