The Ockenden Report

Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust

Published on 10 Dec 2020. It is an interim report highlighting immediate actions following their initial findings.

As well as a number of recommendations made for the Trust involved, the report also made seven recommendations for immediate actions for NHS maternity services nationwide:

  1. Enhanced Safety

The report calls for increased collaboration and partnerships between Trusts, and states the need for Local Maternity Systems (LMSs) to be given greater oversight and responsibility for maternity safety. The report emphasises the need for transparency including the use of external experts for review of Serious Incidents (SIs), and reporting SIs to the local LMS.

  1. Listening to Women and Families

The report states the need for Trusts to ensure that the voices of women and families are listened to and heard. Again calling for the improvement of external engagement and oversight to aid change and transparency, it states Trusts must have independent external advocates who are answerable not just to the Trust, but also to the LMS. It also reaffirms the need for collaboration between board-level staff and maternity safety champions within the team, and engagement with local Maternity Voices Partnerships.

  1. Staff training and working together

The report identifies the vital importance of staff both working and training together to get the most effective multi-disciplinary teamworking environment, which has long been identified in many professional environments (such as aviation). It states that it is important for maternity training funds to be protected and used only for that purpose, and again calls for oversight and validation of collaborative training to be passed to the LMS.

  1. Managing Complex Pregnancy

The Ockenden Report states “there must be robust pathways in place for managing women with complex pregnancies”, and states that there is an urgent need to create regional hub and spoke models to ensure that specialist centres and clinicians can be engaged promptly where appropriately, whether through discussion and support or through referral to a specialist tertiary centre.

  1. Risk Assessment throughout Pregnancy

Formal risk assessments should be undertaken at every contact during their pregnancy to ensure that they are receiving care from the most appropriate professionals and that their intended place of birth is consistently assessed in line with their clinical picture – again emphasising the importance of listening to women.

  1. Monitoring Fetal Wellbeing

The Ockenden Report calls for a dedicated Lead Midwife and Lead Obstetrician with seniority and specific experience to be a recognized focal point to provide leadership for fetal monitoring, including improving best practice in their service, implementing regular training, and ensuring compliance with the Saving Babies Lives Care Bundle (version 2) and future guidelines as they emerge.

Many Trusts have moved quickly to appoint Fetal Monitoring Midwives into formal roles.

  1. Informed Consent

The need for provision of accurate and evidence-based information to help women reach and express informed choices is recognised as essential, and emphasises the need to listen to women and families and make them an active part of the decision-making process about their care.

The full report can be read here.