Independent Review of Maternity Services. Okenden report - final. 2022. (accessed 26 April 2022)

Nursing and Midwifery Council. NMC statement in response to publication of the Ockenden Maternity Review. 2022. (accessed 26 April 2022)

Royal College of Midwives. Government must fix maternity staffing crisis to ensure safety RCM tells TUC Women's Conference. 2022. (accessed 27 April 2022)

The Ockenden report: what are the next steps?

02 May 2022
Volume 30 · Issue 5

The Independent Review of Maternity Services (2022) has published their final report from their investigation into the Shrewsbury and Telford Hospital NHS Trust on 30 March. This update to the initial report published at the end of 2020 highlights essential actions that the report recommends be undertaken, in light of the findings from this review. These findings include ‘patterns of repeated poor care’ and a ‘failure in governance and leadership’ that resulted in systemic oversights during maternity care at the Trust (Independent Review of Maternity Services, 2022).

The report's findings indicate that many families have been affected by tragic circumstances that could have been avoidable. It is heartbreaking to hear, and we can only hope that this report leads to improvements that help avoid these circumstances in future. It is thanks to the tireless efforts of the affected families, the review team and all those who cooperated with and contributed to the report that it has been possible to identify these concerns.

It is clear that the last two years have been incredibly difficult, and healthcare workers across the board have had to handle the pandemic, an unprecendented situation, while facing staff shortages, pay concerns and other issues (Royal College of Midwives, 2022).

The action points outlined in the report aim to ensure services learn from the issues highlighted by the review, and improve the services provided to patients and their families. These points are separated into over 60 ‘local actions for learning’ that apply to the Shewsbury and Telford Hospital NHS Trust, and 15 ‘immediate and essential actions’, which include:

  • Significant investment in the maternity workforce and multiprofessional training
  • Suspension of the midwifery continuity of carer model until safe staffing is shown
  • Strengthened accountability for care improvements among senior staff
  • Timely implementation of changes to practice and improved investigations involving families.

These actions can and should be applied to all services, not just the specific Trust reviewed in the report. The findings have led to a clear opportunity to learn from mistakes and improve future services. Andrea Sutcliffe, Chief Executive and Registrar at the Nursing and Midwifery Council (2022) emphasised this, and said the report is ‘pointing the way to make sustainable improvements in maternity care’. She also highlighted that ‘it is essential that families are heard, staff are able to speak up and concerns are acted upon’.