RCPCH and BAPM statement – response to the Ockenden review

On 30 March 2022 Donna Ockenden published the ‘findings, conclusions and essential actions’ following her independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust.
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The Ockenden review was launched in 2017 by then Health Secretary, Rt Hon Jeremy Hunt MP on the basis of 23 deaths at the Shrewsbury and Telford NHS Trust. Since the initial launch of the inquiry, many more families have come forward, and the review team has heard from 1,486 families with the earliest case from 1973 and the latest from 2020. 

Staff were also given an opportunity to respond. The report states that in 2021 the review team interviewed 60 present and former members of staff about their opinions on the maternity services they worked within. Separately 84 staff responded to a questionnaire about the review.

The Ockenden review outlines a number of concerns and 60 recommendations across: 

  • Patterns of repeated poor care
  • Failure in governance and leadership
  • Local Actions for Learning and Immediate and Essential Actions

The first report was published in January 2021, looking at the first 250 of those cases. 

You can read the final report.

In response to the publication Steve Turner, Registrar at the Royal College of Paediatrics and Child Health (RCPCH) said: 

As a College, our hearts go out to all the families involved, and while nothing can change the ordeal they faced, or bring back the loved ones they lost, we hope the report conveys the overwhelming need for change and improvements in care, so that no other families have to go through similar ordeals.  

We are grateful to Donna and her team for bringing together this report, for continuing to put the families involved at the centre, and for the 60 recommendations to improve the care and culture at the Trust. 

There are lessons to be learnt across the system. It is imperative that the terrible failings documented here over two decades are understood in order that all of the NHS can learn from them. It is shocking that clinical and managerial staff felt unable to speak out about what was happening for fear of retribution. There needs to be a culture of open and continuous learning to ensure high quality care and treatment for patients.  

We strongly welcome the recommendation for the Royal Colleges, Health Education England and Government to consider what makes, and how to fund and support, a safe maternity workforce, with considerations of the neonatal workforce alongside this. We look forward to taking forward these discussions. 

We will now consider all the recommendations in detail.

In response to the report, Helen Mactier President of the British Association of Perinatal Medicine (BAPM) and Consultant Neonatologist said: 

We want to thank Donna and her team for their work to bring together this report, which must have been at times extremely distressing. Our thoughts go to the families who have been harmed by the policies and culture at the Trust these past decades.

All neonatal professionals are absolutely clear that women and babies are safest when the entire perinatal team works and trains together and where there are the right levels of resourcing for maternity and neonatal services. And when things do go wrong, we must all work together and learn from mistakes in an open and honest forum.

We are pleased that the Review team has endorsed the recommendations of the Neonatal Critical Care Review and agree with comments made by staff at the Trust, that there needs to be independent external scrutiny of serious incidents to facilitate improvement. 

As an organisation we will now review and reflect upon the recommendations and support improvements which could impact positively on outcomes for mothers, babies and their families in this Trust and across the entire system.