An overview of the Ockenden Report

There’s no doubt that the long awaited Ockenden Report – an independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust – is a hard read. The findings are damning and the stories from families are truly heart-breaking.

As someone who has worked within the birthing/parenting world for 20 years, the failings highlighted by Donna Ockenden are inexcusable but the findings for immediate change could make a crucial difference for all families.

Communication, listening to and learning from parents is essential to providing effective care. There is no excuse for dismissing and ignoring parents.

Some of the main comments in the Ockenden Report:

  • Donna Ockenden acknowledges the efforts and exhaustion of the NHS, especially throughout the pandemic before focusing on the NHS maternity unit that failed.
  • “Even now there remains concerns that NHS maternity services are still failing to adequately address and learn lessons from serious maternity events occurring now.”
  • “Workforce challenges that have existed for more than a decade cannot be put right overnight…the size and scale of this review is unprecedented in NHS history…we have been given a once in a generation opportunity to improve the safety and quality of maternity services provision for families now and in the future.”
  • “60 past and present staff members were interviewed but in the final weeks before publication of the Ockenden Report, a number of staff withdrew and their voices were lost from the report. They feared being identified.”
  • “It is absolutely clear that there is an urgent need for a robust and funded maternity workforce plan, starting right now, without delay and continuing over multiple years…Without this, maternity services cannot provide safe and effective care for women and babies.”
  • “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.”

Some of the concerns raised:

  • maternity staff failed to recognise CTG tracings
  • NICE guidelines weren’t always followed
  • lack of staff training
  • workforce issues
  • inadequate risk assessments
  • low morale among midwives
  • no evidence of action plans to make change
  • lack of resuscitation equipment and experience with using it

The immediate and essentials actions (IEA) to improve care and safety include:

  1. Effective funding to ensure safe staffing levels, along with well-trained maternity staff, across all levels
  2. Clear pathways of care and services for pregnant women, with effective communication
  3. Clear guidelines and processes for staff to escalate any concerns
  4. NHS Trust boards are to review the quality and performance of their maternity services
  5. To learn from any incidents and to create action plans for change
  6. To listen to parents

The findings of the Ockenden Report state that maternity services need immediate and ongoing investment to recruit enough staff, to provide staff with effective training and to create clear pathways and systems to report problems and concerns and to learn from families.

We now need to see what changes are put in place as a result of the Ockenden Report and how these are assessed and reviewed. This is an opportunity to ensure that maternity services across the country are safe for women and their babies.

No service will ever be perfect but women should be listened and responded to, they should be cared for, they should be safe.

I am going to write a follow up post to focus on what you can do to manage your maternity care because I am sure this report has raised some concerns for anyone who is pregnant. Please do get in touch with any comments or questions.

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A specialist in pregnancy, birth and early parenting

Working with parents since 2002

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