Maternity Care Failings in England: Lessons from Ockenden and the Risks of Dual-Site Services

Maternity Care Failings: A Continuing Concern

An article recently highlighted in The Times, asking whether this could be Britain’s worst maternity scandal, raises deeply troubling questions about the state of maternity care in England. It points to systemic failings affecting both mothers and babies; issues that, for many families and practitioners, are sadly not new.

Working in Leeds and specialising in cases involving stillbirth, neonatal death and birth injury, these reports do not come as a surprise to me. Instead, they reinforce a growing sense of concern shared by those who work closely with affected families. Behind the headlines are real people whose lives have been permanently altered.

For those supporting families through these experiences, the concerns reflect patterns we see repeatedly. They echo the findings of the Donna Ockenden Review into maternity services at Shrewsbury and Telford NHS Trust, which exposed widespread and long-standing failures in care.

Recurring Themes in Maternity Care Failures

The Ockenden Review identified a number of serious and repeated failings, including failures to escalate concerns, poor fetal monitoring and interpretation, and missed opportunities to intervene during labour. There were also inadequate responses to known risk factors such as infection, growth restriction, gestational diabetes and prior obstetric complications.

Perhaps most concerning were persistent communication failures. Many women reported that they “knew something was wrong, but were not listened to.” This theme continues to emerge across cases nationally.

Although these findings relate to specific Trusts, the issues are not confined to one region. Investigations into maternity failings are often lengthy and distressing for families. The recurrence of similar issues across different Trusts raises difficult questions about whether lessons are being effectively shared across what is intended to be a truly national health service.

Pressures Within Modern Maternity Services

In cities such as Leeds, maternity services face additional structural challenges. Leeds Teaching Hospitals NHS Trust, like many large NHS providers, delivers care across more than one site. While this can offer flexibility, it also requires careful coordination to ensure patient safety is not compromised.

Dual-site maternity services can introduce additional risks where systems, communication, or staffing are not sufficiently robust.

The Challenges of Dual-Site Maternity Care

One of the most significant risks arises in situations requiring urgent escalation or intervention. Where a mother or baby must be transferred between sites to access higher-level care, delays can occur. In intrapartum emergencies, particularly where fetal compromise is suspected, timing is often critical and can directly affect outcomes.

There is also the potential for inconsistency in care. Differences in staffing levels, clinical experience, or local practices between sites can lead to variation in decision-making. For families, this may result in fragmented care at a time when continuity is essential.

Clear and effective communication is fundamental to safe maternity care. Operating across multiple sites increases the risk of miscommunication between teams, delays in sharing clinical information, and uncertainty over responsibility for key decisions. These risks are further compounded by staffing pressures. Dual-site models can stretch limited resources, particularly in relation to senior obstetric cover, experienced midwifery staff, and continuous CTG interpretation.

When these factors combine, there is a heightened risk that warning signs may be missed or that intervention may be delayed.

Impact on Families

Where care spans multiple sites, families may understandably question whether delays in transfer affected the outcome, whether appropriate care was available at the right time, and whether systems were designed with patient safety at their core.

For those affected by stillbirth, neonatal death or serious birth injury, these questions are not abstract. They go to the heart of understanding what happened and whether it could, or should, have been prevented.

Supporting Families and Seeking Accountability

Pursuing answers after such events is never easy. Investigations can be complex, lengthy and emotionally demanding. Families require clear guidance, sensitivity and trust throughout the process.

Where concerns arise about maternity care, early specialist advice can help families understand what happened, whether failures occurred, and what steps can be taken. This may include seeking accountability, ensuring lessons are learned, and, where appropriate, pursuing compensation.

For those who have experienced issues similar to those described, it is important to know that support is available. Asking the right questions is often the first step towards clarity, accountability and, ultimately, change.

How Forbes Solicitors Can Help You

Leonie Millard, a specialist in stillbirth, neonatal death and birth injury claims, is part of Forbes Solicitors’ expert Clinical Negligence team. She works closely with families to provide clear advice, strong legal support, and a sensitive approach throughout what can be an incredibly challenging process.

Our team can assess your experience, determine whether the care you received fell below an acceptable standard, and advise if you may have grounds for a claim. We offer consultations via telephone, video call, or at any of our offices.