Medical Negligence

Maternity services in the spotlight: Ockenden Review and Maternity Reporting

November 3, 2022
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Written by Senior Solicitor, Trevor Ward

The publication of the Ockenden Review into maternity services over nearly 20 years at the Shrewsbury and Telford NHS Trust raised again the question of the standard of maternity services in the UK.

Whilst the report illustrated widespread and cultural issues at this particular Trust, history tells us (Morecambe Bay, Wales) that these issues are unlikely to be isolated to Shrewsbury and Telford only.


There are about 700,000 births per annum in England and Wales. 40% are first baby and most have no issues. 90% are single pregnancies beyond 37 weeks gestation and with baby’s presentation head first.

Approximately 5% of the overall pregnancies will have a complication of gestational diabetes and 8-10% will have the complication of hypertension and will need careful management.

Principle maternity investigations

The National Maternity Review published its initial findings in 2016 and led to The Maternity Transformation Programme. The scope of the review was to assess current maternity care provision and consider how services should be developed to meet the changing needs of women and babies.

It made proposals to make care safer and to give women greater control and more choices. Key areas were identified

• Personalised care
• Continuity of carer
• Better postnatal and perinatal mental health care
• A better payment system (for Trusts)
• Safer care
• Multi professional working (breaking down barriers between midwives, obstetricians and other professionals)
• Working across boundaries

The Healthcare Safety Investigation Branch (HSIB) is tasked with conducting independent investigations of incidents in NHS-funded care across England. It has been recognised for some time that most harm in healthcare results from problems within the systems and processes that determine how care is delivered.

In relation to maternity services and maternity investigations, HSIB carried out investigations from 1st April 2018 through to December 2019. Essentially HSIB investigations replace Trusts’ internal responsibility for investigating, although each Trust remained responsible for exercising its Duty of Candour and referring particular incidents to HSIB in the first instance.

In the above period, HSIB investigated over 1000 incidents of which 280 investigations related to maternity services (plus another 146 investigations in the period being checked for factual accuracy but not concluded at the time of the report).

Various themes were identified:

• The need for early recognition of risk
• The safety of intrapartum care
• The appropriate need for escalation
• Handover issues between shifts/colleagues
• The problems associated with larger babies
• Dealing with neonatal collapse
• Group B streptococcus
• Cultural issues

In February 2022, the Care Quality Commission published its results for the 2021 Maternity Survey. Responses to the survey were received from 23,000 women with an increase in online reporting during the pandemic. It did report year on year improvement with positive benefits reported in continuity of care, mental health support and interaction with staff. However, problems were identified in other areas.
If one reads the investigation report, one can see that the same themes as in 2016 and as reflected in the Ockenden Report and HSIB resurface –

• Lack of personalised care and review in the antenatal period
• Too rigid adherence to maternity pathways for initial low risk pregnancies
• Breaking boundaries to allow for ‘fresh eyes review’
• A recognition that 2018 MBRRACE-UK a 5-fold increase in mortality for women of black ethnic origin and 2-fold increase for women of Asian ethnic origin

The Sunday Times reported on 10th April 2022 that almost half of NHS maternity services in England are unsafe. They suggested that babies’ lives were at risk because maternity units were still unsafe years after families raised concerns about preventable deaths resulting from poor care.

Of the 193 NHS maternity services in England, 80 are rated as “inadequate” or “requires improvement”, meaning they do not meet basic safety standards.

Parents whose babies died avoidably have said they feel guilt that other families have suffered the same fate because hospitals have not investigated incidents and improved care.


There will be continual learning from these and further planned reviews and reporting – it is too expensive to society in all respects not to do so. We must all continue to strive for adequate time for staff and adequate resource of both staff and facilities for ongoing maternity services In England and Wales.

Trevor Ward is a Senior Solicitor and the Head of the Birth Injury Unit at Fletchers Solicitors, as well as the Chief Assessor for The Law Society’s Medical Negligence Panel. If you or your baby has suffered due to negligence, we can guide you through the legal process – call us now on 0330 013 0251.

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