The Ockenden Report, an independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, commenced in 2017 to investigate concerns about maternity care. The inquiry expanded to cover 1,486 families, mostly between 2000 and 2019, after beginning with 23 cases. The review team examined 1,592 clinical incidents, with the earliest case from 1973 and the latest from 2020. The report revealed systemic failings in the provision of maternity care at the trust, including repeated errors in care leading to injury or death of mothers and babies. It found that 201 babies could have survived with better care and identified significant or major concerns in the care of nearly a third of all incidents reviewed (27.9%).
The report highlighted a culture of bullying and fear among staff, which led to a reluctance to speak out about failings. This culture, combined with failures in leadership and teamwork, resulted in the trust’s inability to adequately investigate, learn from, and improve upon critical incidents. The review identified thematic patterns of poor care and missed opportunities for learning and improving quality of care.Donna Ockenden, who led the review, emphasized the urgent need for a robust, funded, and long-term England-wide maternity workforce plan. The review team outlined 15 immediate and essential actions that must be implemented by all trusts in England providing maternity services. These actions encompass workforce funding, planning, safe staffing, leadership, investigations, complaint handling, multidisciplinary training, and various aspects of maternity care.
The Ockenden Report’s findings are consistent with previous investigations into NHS services, underscoring persistent issues like a culture of not listening to patients, failure in leadership, and inadequate responses to adverse incidents. The government has recognized the need for investment in the maternity workforce, but this falls short of the comprehensive plan demanded by the report.
What were the top 3 key messages of the Ockenden Report?
- Systemic Failures in Maternity Care: The report highlighted repeated errors in maternity care that led to harm or death for mothers and babies. It emphasized the need for fundamental changes in how maternity care is delivered and managed. This includes addressing failures in investigating incidents, learning from them, and making necessary improvements.
- Culture of Fear and Silence Among Staff: A significant issue identified was the culture of bullying and fear within the hospital staff, which hindered open communication about problems in patient care. The report emphasized that staff were often afraid to speak out about failings due to fear of retribution. This culture contributed to the failure in addressing and rectifying issues in the maternity services.
- Urgent Need for a Comprehensive Maternity Workforce Plan: The Ockenden Report called for an urgent and robust maternity workforce plan, emphasizing the necessity of proper funding and long-term planning. This plan should include measures for safe staffing, leadership, training, and various aspects of maternity care to ensure the safety and quality of services provided to families.
These key messages highlight the need for systemic reform, cultural change, and strategic planning to improve the quality and safety of maternity services.
15 key actions
The Ockenden Report outlines 15 immediate and essential actions to improve maternity services in England. These include:
- Strengthen leadership skills in maternity and neonatal care.
- Increase the number of midwives and obstetricians.
- Improve risk assessments in maternity care.
- Enhance monitoring of fetal wellbeing.
- Implement a standardized approach to intrapartum care.
- Ensure effective escalation processes in maternity care.
- Improve postnatal care.
- Enhance neonatal care and support.
- Develop a comprehensive preterm birth surveillance system.
- Improve the management of complex pregnancies.
- Establish robust mechanisms for learning from incidents.
- Enhance support for families after adverse events.
- Strengthen multidisciplinary teamwork and training.
- Improve transparency and accountability in maternity services.
- Enhance patient engagement and feedback mechanisms.