MAMA Academy Statement For Final Ockenden Report

Published on: 30/03/2022

MAMA Academy welcomes today’s release of the final report of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospitals NHS Trust, led by MAMA Academy Patron, Donna Ockenden.

This Review has looked at almost 1600 clinical incidents and identified repeated failures to listen to families, to both review effectively and learn from clinical incidents, and repeated failure of external bodies to provide effective oversight of care being provided.

The Ockenden Review makes for difficult reading, but highlights central themes that need appropriate focus both locally and across the entire maternity service to ensure that lessons are learnt everywhere to avoid such devastating outcomes being repeated.

Donna Ockenden has made clear that a lack of staff and a lack of ongoing training were critical factors, as well as governance and cultural failings, saying “this highlights that systemic change is needed locally and nationally to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require.

It is really important to recognise that this report is not an attack on midwives, nor does it lay all responsibility for failures with front-line staff. This review highlights systemic and structural failures, and it is by resolving these that services can be improved in a sustained and sustainable way.

Whilst issuing a large number of local actions for learning to be undertaken by the Trust concerned, the Review also issues 15 Immediate and Essential Actions – Actions, not recommendations – for nationwide improvement, across ten key areas. These are:

  1. Financing a safe maternity workforce – a proper nationwide plan for investment to ensure a well-staffed workforce, with appropriate minimum staffing levels agreed and adhered to.


  1. Essential action on training – protected time to ensure that appropriate training is maintained across all staff, including refresher training and multidisciplinary team training (team members with different roles, such as midwives, obstetricians, and anaesthetists who work together must also train together), especially regarding emergency drills.


  1. Maintaining a clear escalation and mitigation policy when agreed staffing levels are not met – making sure that escalation is followed will ensure that gaps in staffing are properly highlighted at all levels where they need to be identified, including senior management, Trust board, Trust patient safety champion, and the local maternity system (LMS) – which is essential to ensure that there is visibility and oversight outside an individual Trust. Midwifery Continuity of Carer should be suspended unless it can be adequately staffed.


  1. Essential roles for Trust Boards in oversight of maternity services – Boards need to ensure that they have regular reporting and reviews to drive improvement, and should ensure that a patient safety specialist dedicated to maternity services exists. This is important to ensure that regular visibility of the state of play of maternity services exists outside of the department.


  1. Meaningful incident investigations with family and staff engagement – involving families is important both for their own experience and their understanding, as well as the understanding of the system about their essential perspective of any incident. Transparency is vital to drive improvement, so language needs to be easy to understand for parents and they should be properly supported. Changes should be made – and be seen to have been made – within six months.


  1. Mandatory joint learning when a mother dies – reviews of maternal deaths must include staff from every single clinical setting involved in their care, to ensure that learning is both proper and widespread. As above, changes should be made – and be seen to have been made – within six months. Families must not be kept in the dark and have to chase for findings.


  1. Care for complex and multiple pregnancies – complex pregnancies require appropriate care from specialists experienced in managing their complexity. Collaboration with nearby Trusts is necessary – and should happen early – if a unit does not have this expertise in-house.


  1. Ensuring the recommendations from the 2019 Neonatal Critical Care Review are introduced at pace – making sure that babies born at earlier gestations who require Neonatal critical care are, wherever possible, supported in the appropriate units from the outset is an important element of improving neonatal outcomes.


  1. Improving postnatal care for the unwell mother – systems must exist to ensure that birthing people readmitted to hospital in the postnatal period are appropriately cared for. Again, the Review highlights the need for appropriate staffing levels to ensure this – this is essential to improving care.


  1. Care of bereaved families – bereavement services need to be available 24/7, not just during working hours or the working week. Bereaved families – like all families – need appropriate support when they need it, not later.


Heidi Eldridge, Chief Executive Officer at MAMA Academy, said:

“Donna Ockenden’s review is a painstakingly thorough investigation and has highlighted a number of immediate and essential actions to improve maternity services across the entire country. It is clear from this review that there is plenty of work still to do, and we must all redouble our efforts to achieve the changes outlined in today’s report. Safe maternity care isn’t an ambition, it’s a right.

This report highlights the need for increased funding, a properly resourced workforce, protected opportunities for staff to train – particularly on critical aspects of safety, and robust, timely investigations when things go wrong, making sure lessons are properly learnt so that mistakes aren’t repeated.

This review shows the need to make systemic and structural changes to maternity services to improve care, but it is also important to acknowledge the incredible work being done by the overwhelming majority of midwives, obstetricians and other health professionals providing care – these systemic improvements will better equip them with the tools and resources they need to improve the care they are able to provide still further.

MAMA Academy welcomes the £127m investment announced last week and urges the Department for Health to ensure that no stone is left unturned in implementing the blueprint for the way forward to maternity safety provided by the Ockenden Review. MAMA Academy will continue to work with NHS Trusts all over the country to support them in helping more babies arrive safely.

Today we hold in our thoughts the many families and babies whose experiences have contributed to the Ockenden Review, and other families up and down the land who have experienced tragic outcomes. This report will be particularly difficult for them to hear, and whilst this journey to maternity safety is not an easy one to take, it is a road we have to travel.”