Ockenden Report Maternity Failures: When will they learn?

Leonie Millard
Leonie Millard

Published: November 14th, 2023

6 min

Another set of parents have felt compelled to highlight ongoing issues with maternity services at the Shrewsbury and Telford Hospitals NHS Trust following the death of their daughter.

This comes after the release of the Ockenden report following an enquiry into maternity services at Nottingham University Hospitals NHS Trust. It examined cases involving 1,486 families and found 201 babies and 9 mothers could or would have survived if they had received better care. There were at least 94 instances of brain injury to babies.

The 4 pillars of essential action were;

  • Safe staffing levels, properly funded.

  • A well trained workforce.

  • Learning from incidents.

  • Listening to families.

The report found that the Trust failed to investigate, failed to learn and failed to improve. The repeated failure spanned over 20 years.

It is understandable to think that in response to the criticism there would be significant impactful change. The report, published 18 months ago set out the actions for learning, yet despite the intense scrutiny other families still have reason to complain. The same problems with maternity care continue to raise their heads. Donna Ockenden agrees that not enough has been done since her report.

Kate and Neil Russell reported their experiences having lost their child when her heartbeat was not properly monitored by a midwife, and she was starved of oxygen. She died 11 hours after delivery by emergency caesarean section, on the 11th April 2021.

In this sad case, the mother reports that the trust staff painted a picture of her as 'a difficult patient'. The coroner rejected the allegation at the inquest that she had declined monitoring. The coroner concluded 'it is inconceivable that she would have changed her mind and wanted anything less'. Her birth plan listed as the first priority, regular monitoring of the baby's heartbeat. It's a further example of the trust seeking to blame families. It once again demonstrates a lack of accountability and the extent the trust would go to to hide what they had done.

Neil Russell said, 'even a week before the inquest they were challenging the experts reports that said monitoring had not happened'.

Often, as solicitors, we rely on experts to determine what the most likely chain of events is in the circumstances. The trust deliver a lot of babies and tend to rely on their notes to support what they are saying. For the families involved, the experience is unique and they often vividly remember everything.

The parents had their own integrity challenged whilst grieving for the death of their daughter, and have still not received a direct apology. Donna Ockenden has commented 'there is a culture at that trust of deflection and blaming families and I am deeply saddened to hear that this continued to be the experience for Poppy's parents'.

It is now always easy to find a voice after you have lost a baby or are caring for one with a catastrophic injury, but this case emphasis the importance of speaking up. More needs to be done against a background in an increase in stillbirth in 2021 and the number of mothers dying.

I echo the concerns raised by Kate Russell 'this is not just a case of 1 Trust. This seems to be right across the country.'

I represent women from all over the country, spanning several Trusts and the same challenges and issues arise. The families that I represent would support a request for a national enquiry.

Despite the government confirming that 165 million a year was invested following Ockenden report to grow the maternity workforce this is another example of where the four pillars of essential action have not been upheld.

According the CQC nearly 2/3rds of England's maternity services are rated inadequate or requiring improvement for safety.

For further information please contact Leonie Millard

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