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Ockenden Review: An overview of one of the country's worst health scandals and what the national maternity picture is like

By Rowen Cobb, a medical negligence expert at Irwin Mitchell

In 2017, independent midwife Donna Ockenden was asked to investigate 23 cases of concern at the Shrewsbury and Telford Hospital Trust. Since 2017, hundreds of families have come forward and the long-awaited report has been published.

The inquiry, which analysed the experiences of more than 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 found that at least 12 mums died while giving birth, and some families lost more than one child in separate incidents.

Sadly, more than 200 babies died or were left brain-damaged due to inadequate care at the Trust.

Irwin Mitchell is currently supporting a number of families affected by maternity issues at the Shrewsbury and Telford Hospital Trust as well as other hospitals across the UK.

Consultant Obstetrician – Bernie Bentick 

Mr Bentick was a consultant obstetrician for the Trust for almost 30 years. 

He said that “there was a climate of fear where staff felt unable to speak up because of risk of victimisation”. 

Mr Bentick has further stated that “there were significant issues which promoted risk because of principally understaffing and the culture”. 

He also has accused hospital bosses of prioritising activity – the number of patients seen, and procedures performed – over patient safety”.

Former Senior Midwife - Donna Ockenden

Donna Ockenden led the inquiry with the input of more than 90 midwives and doctors. Mrs Ockenden said her team had been “shocked and saddened” by the scale of the tragedy.

The report has revealed that hundreds of babies were stillborn, died shortly after birth or were left permanently brain-damaged while many had fractured skulls or broken bones, or were left with life-changing disabilities.

Donna Ockenden notes that: “There were numerous opportunities for the system to wake up and realise that there was a problem at this Trust. 

"There have been a number of occasions where families tried to be heard over many years and were silenced or ignored. We have seen families that have been split apart, families where relationships have been broken, cases of trauma and PTSD that have been persisted for years after the event as well as terrible sadness”.

Response of Shrewsbury and Telford Trust

An NHS spokesperson stated that “We have already taken significant action to transform our care for pregnant women and their babies with an additional £127 million to been announced to boost the maternity workforce and improve workplace culture for staff within the NHS."

Following the report, Shrewsbury and Telford Trust apologised to affected families and described the report as “deeply distressing” and note that many changes highlighted in the report had already been introduced.


Julie Rowlings, who lost her daughter Olivia, in 2002, has said: “The publication of the report meant Olivia finally had a voice. She has been heard so it gives her death a purpose and it gives all this pain and anguish which we continually put ourselves through to try and get change”.

Maternity care nationally

Donna Ockenden has made national recommendations – some of which have been implemented with immediate effect.  While we welcome the recommendations made, and can only hope that the action that has been taken will prevent such a scandal from reoccurring, the failings at Shrewsbury and Telford don't appear to be an isolated incident.

A review is under way into maternity services at Nottinghamshire University Hospitals NHS Trust, with the number of families coming forward increasing from 87 to 387 in just a few weeks. There have further been concerns raised of the maternity care received at Basildon Hospital, East Kent Hospitals as well as at Sheffield Teaching Hospitals NHS Foundation Trust. Just this week the Care Quality Commission raised concerns about maternity services at the Trust not improving.

It's extremely worrying that concerns remain nationally about maternity safety and it's important that there's now lasting change. In the meantime we continue to support families nationally but also campaign for change.

Find out more about Irwin Mitchell’s expertise in supporting families affected by maternity care issues at our dedicated medical negligence section.

The stories about some of the families we're supporting following care issues can be found at the maternity safety section of our website.

It's extremely worrying that concerns remain nationally about maternity safety and it's important that there's now lasting change. In the meantime we continue to support families nationally but also campaign for change.”