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Britain’s worst maternity scandal – will lessons be learned?

Ockenden Inquiry into maternity services at the Shrewsbury and Telford Hospital NHS Trust


You may have seen a lot in the news about the Ockenden Inquiry into maternity services at the Shrewsbury and Telford Hospital NHS Trust. The inquiry reviewed almost 1,600 maternity incidents over a 20-year period and found that 201 babies could have survived had the Trust provided appropriate care. When the inquiry was first commissioned, it was intended to examine 23 cases, but this escalated to a concerning 1,592 cases, all associated with the same Trust.

In addition, there was avoidable harm caused to many other babies, some now left with significant lifelong conditions. Mothers were also subjected to unacceptable care and suffered harm and nine mothers died.


Why did this go unnoticed for 20 years?

It didn’t. The Trust had been referred to the Healthcare Commission (HCC) and Clinical Commissioning Group (CCG) for investigation. Despite this, the investigators either failed to undertake the investigation or the investigation was inadequate allowing the Trust to continue its practices.

The inquiry worryingly revealed there was a culture of failing to listen to the families, in particular the mothers’ concerns or wishes.


What is the outcome of the inquiry?

The outcome of the inquiry has made a wide range of recommendations, the majority for that particular Trust, fifteen for NHS maternity providers in general and a small amount for the government. It has thrown a spotlight on significant failings, and it is only now, many years on in some cases, that an active police investigation is underway.


It is surprising that even recently these tragedies are still occurring, with mothers and babies paying the ultimate price. We should perhaps all commend the brave 1,486 families who stood together and prompted the inquiry at the outset, and the hundreds of families whose very painful experiences were shared during Donna Ockenden’s independent review.


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