Ockenden Review Calls for Immediate Action in Maternity Units

Posted on: 6 mins read
Last updated:
Georgina Emsley

Solicitor, Medical Negligence

Share Article:

Shrewsbury and Telford Hospital NHS Trust has been told to implement “essential and immediate actions” following concerns over patient safety in its maternity services. An independent review into conduct of the Trust was commissioned by the Government following the tragic case of Kate Stanton-Davies, who died just 6 hours after her birth whilst under the care of the Trust in 2009.

Our own medical negligence solicitors represented her devastated parents and we consider the report findings are a step in the right direction.

a baby holding their parent's hand

Get in touch today!

If you or your child has suffered as a result of hospital negligence, get in touch with our team to see how we can help.

What is the Ockenden Review?

The Ockenden Review is looking into the cases of thousands of families who have suffered as a result of failings in maternity care at the Trust.

The Review was the largest one of it kind and it included the experiences of:

  • Stillbirths
  • Neonatal deaths
  • Babies with brain damage
  • Maternal deaths
  • Mothers who suffered serious injuries

The above isn’t exhaustive, but it highlights the depth of the Review. The purpose of the Review was to highlight where the main areas of failings were, to better the NHS for the future.

Ockenden Review Findings

Through the Ockenden Review, it was discovered that around 201 babies could have survived, had they received reasonable care.

As a result of poor maternity care, many mothers also sadly passed away due to their injuries.

The report demonstrates that there was simply not enough training and that deaths were not being investigated properly, to determine the cause and/or any trends.

A total of 1,815 cases were included in the review, ranging from incidents that happened between 1973 to 2020:

  • 12 maternal deaths – 3 had major concerns and 6 had significant concerns in care
  • 498 stillbirths – 1 in 4 had significant or major concerns in care
  • Newborn brain injury – 65.9% had significant or major concerns in care
  • Neonatal death – 27.9% had significant or major concerns in care

a mother laying with her newborn baby

Ockenden Report Recommendations

The Ockenden Report into Shrewsbury and Telford Hospital NHS Trust put forward a number of recommendations and has called for a greater emphasis on training, communication, and risk management. Donna Ockenden (Maternity Expert) has urged for the recommendations to be implemented at The Shrewsbury and Telford Hospital NHS Trust as soon as possible and recommendations should be given thorough consideration in all maternity units across England.

These recommendations cover 7 key areas which are:

Enhanced Safety

Safety in maternity units across England must be improved. Neighbouring Trusts must work together so that local investigations into Serious Incidents have regional and Local Maternity System (LMS) oversight.

Listening to Women and Families

Creation of an independent senior advocate role whose duty is to report to the Trust and the LMS board. The advocate must be available to families at meetings with medical practitioners where concerns about maternity or neonatal care are raised, especially where there has been an adverse outcome. CQC inspections must include assessments of whether women’s voices are truly heard by the maternity service, with involvement of the Maternity Voice Partnership.

Staff Training and Working Together

Regular training which must be validated by the LMS 3 times a year, twice daily Consultant led ward rounds, and ring-fencing training funding for maternity staff.

Managing Complex Pregnancy

There must be clear pathways for managing women with complex pregnancies. These pathways should be developed by agreeing the criteria for those cases and/or referring them to a Maternal Medicine Specialist Centre.

Risk Assessment Throughout Pregnancy

Practitioners must ensure that women are risk assessed at every contact and appropriately, throughout their pregnancy.

Monitoring Foetal Wellbeing

There must be a dedicated Lead Midwife and Lead Obstetrician to focus on foetal monitoring throughout pregnancy.

Informed Consent

All Trusts must ensure that mothers have access to accurate information which will afford them the opportunities to make informed choices about their place and chosen birth method.

A member of the team here at Simpson Millar said: “The families involved in this review have waited years for answers, and for justice to be done. While the initial recommendations appear to address some of the many, many concerns highlighted as part of the cases under review, the reality is that there is no one holding failing Trusts across the country to account when it comes to implementing such change. Until that happens, I’m afraid the struggle and heartache of so many bereaved parents have simply not been recognised, and they will take limited comfort that lessons have truly been learnt. As the review into the 1862 cases continues, we would urge the review committee to do more to ensure that all trusts publish their plans and a tangible timeline to provide much needed reassurance – both to those who have already suffered, as well as expectant mothers.”

You can read the full report here.

a picture of a newborn baby

Why Was the Review Set Up?

An independent review into Shrewsbury and Telford Hospital NHS Trust’s maternity services was set up three years ago by the Health Secretary Jeremy Hunt, after concerns were raised by the parents of several babies who died shortly after birth, including the parents of Kate Stanton-Davies.

The review was initially asked to look into 23 cases, but hundreds of reports of avoidable baby deaths, brain damage and stillbirths involving the Trust arose, leading to almost 2,000 cases being investigated.

If you were treated by Shrewsbury and Telford Hospital NHS Trust’s maternity services and think your care may have been negligent, please get in touch with one of our Medical Negligence Solicitors. There’s no obligation to make a claim and were happy to have an informal chat about your situation.

Our Service

We understand how traumatic your experience will have been and when people contact us, they are often feeling emotionally drained, confused and unsure where to turn for help. We take practical steps to ensure a positive outcome while handling your case with great sensitivity.

Our Medical Negligence Solicitors can offer:

  • Free claims assessment
  • No Win, No Fee agreement
  • Legal Aid
  • Negotiation-led approach
  • Aim to settle out of Court
  • Accredited expert solicitors
  • High success rate
  • Sensitive and compassionate approach
  • Free support and advice

How Simpson Millar Can Help

If you or someone you love was a victim of medical negligence, we can help you bring a claim. Should you have any questions at all regarding the Ockenden Review or any potential failings in your maternity care, please get in touch with our team today.

Whilst no amount of compensation can change the devastating impact of medical negligence, a successful claim can help pave the way for change. Every patient voice is important, and it needs to be heard. Each time a Claimant brings a claim for damages arising from medical negligence, it highlights the areas within Trusts that need urgent attention. By commencing investigations into a potential claim, you can get justice and may stop others from falling victim to failings in their care.

Contact one of our specialist Medical Negligence Solicitors today to discuss your claim. We will arrange an initial free claims assessment to gauge what has happened. We understand how difficult it can be seeking legal advice after losing a loved one to medical negligence. Our compassionate team will take everything at a pace you feel comfortable with, and can fully tailor our service to meet your needs. We will endeavour to support you in every way that we can.

How to Start a Medical Negligence Claim

When you get in touch with our team, we will guide you through the legal process of making a claim for clinical negligence. First, you should arrange a free claims assessment with our team to determine whether your case is likely to be successful.

We will then gather evidence to support your claim from medical experts from the suitable disciplines and if appropriate, write a letter to the Defendant (other side) inviting them to accept liability (responsibility) Our approach usually means that we often settle claims outside of Court. We will always aim to reach settlement outside of Court but of course, sometimes this isn’t possible. We will of course represent you and continue to act in your best interests, should your claim go to trial. This would be discussed if appropriate, at the appropriate time.

If you have any questions relating to medical negligence or you want initial legal advice, please get in touch with our team today. We will be happy to provide you with the help you need and can’t wait to hear from you.


Ockenden, D. (2022). Ockenden review: Summary of findings, Conclusions and Essential Actions. [online] GOV.UK. Available at: https://www.gov.uk/government/publications/final-report-of-the-ockenden-review/ockenden-review-summary-of-findings-conclusions-and-essential-actions.

Ockenden, D. (2022). Ockenden report - final. [online] Ockenden Maternity Review. Available at: https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2022/03/FINAL_INDEPENDENT_MATERNITY_REVIEW_OF_MATERNITY_SERVICES_REPORT.pdf.

Georgina Emsley

Solicitor, Medical Negligence

Areas of Expertise:
Medical Negligence

Georgina is a Solicitor who works in our Medical Negligence team here at Simpson Millar, based in our Manchester office.

She is a committed and highly reliable Solicitor with a track record of supporting clients through the process of making a claim to achieve the best outcome for them. Georgina has experience working on many high-value cases with a range of circumstances and complexities from start to finish, where she reviews medical records, liaises with experts and gathers evidence in order to negotiate the best possible settlement for her clients.

Get in touch, today!

Fill in the form below to get in touch with one of our dedicated team members, or call our team today on: 0808 239 6043

This data will only be used by Simpson Millar in accordance with our Privacy Policy for processing your query and for no other purpose