What will the Ockenden Report mean for maternity services and NHS England?

The Chair Donna Ockenden has been tasked with leading the inquiry into more than 800 allegations of poor care at the Shrewsbury and Telford Trust dating back 40 years to the 1970s. The team of experts led by Donna Ockenden will review "multiple maternal deaths, many avoidable baby deaths and many cerebral palsy cases".

This is the biggest maternity scandal in NHS history. Kayleigh Griffiths, whose daughter Pippa died in 2016 after Midwives failed to spot a serious infection told the Independent newspaper "this investigation was ordered due to the high number of avoidable deaths. Everybody should receive good care and a healthy baby/mother at the end of it, not just a percentage".

Criticisms have included unsafe staffing levels with a CQC recording 26% vacancy of midwives in April 2019. In response to the unannounced inspection a further 29 Midwives and 2 new Obstetricians, a new care group Director of Midwifery were recruited, where skills, experience and qualifications to enable the right level of care were at a shortage. Maternity services remain under special measures and a legal warning.

One observation was that there has been a focus on 'normal births, representing this as a positive outcome'. It advocates against caesarean births but highlights greater need for intervention and difficult deliveries.

An NHS commissioned report into maternity services at the Shrewsbury and Telford Hospital Trust suggested it was 'safe' and of 'good quality' and delivered 'a learning organisation'. The report skirted over complaints and lorded an excessive number of unexpected neonatal admissions as an improvement in reporting culture. It was a defensive spin on real issues following avoidable mistakes, far from the learning culture it was supposed to serve.

Light at the end of the tunnel

The first report stemming from the Ockenden inquiry was published 10th December. It made a plethora of recommendations for improvements locally, but also suggestions for improvements across all English maternity services including;

• Increased partnerships between Trusts and within local networks

• Listening to women and families

• Staff groups who work together, training together managing complex pregnancies

• Risk assessment throughout pregnancy

• Monitoring foetal wellbeing and informed consent.