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The Ockenden Review – SaTH

February 2021

Please see below a short video recorded to capture family questions that were submitted to the Maternity Review Team following the publication of our first report

January 2021

The West Midland Ambulance Service (WMAS) had their Board of Directors meeting on 27th January. At the meeting they presented a report which outlined the assurance required to ensure they are delivering the best possible care, as well as learning from the Ockenden report to identify any further actions that WMAS can take to improve care to women who are in labour and who may have complications of labour.

They note that “although, it may appear that the Ockenden report is more applicable towards hospitals, as an emergency ambulance service providing pre-hospital maternity care, it is essential we respond to at least 4 of the 7 Immediate and Essential Action’s (IEA) highlighted within the Ockenden Report which apply to our trust. In addition, there are generic relevant issues that are highlighted in the report and these are highlighted in the enclosed action plan.”

Attached are the papers from the board meeting, please note it is 208 pages long. The section related to the Ockenden report starts on page 37. It also contains their action plan in relation to the Ockenden Report (2020) WMAS Review of Immediate and Essential Actions and Ockenden Report (2020) WMAS Review of Relevant Issues in Report.

Read papers from the board meeting here  

New funding for maternity leadership training following on from the Ockenden maternity review

The Government has announced a £500,000 maternity leadership programme to train senior maternity and neonatal leaders. This follows on from the issue of leadership being identified as a key factor in Donna Ockenden’s independent review into cases of neglect and preventable baby deaths at Shrewsbury and Telford NHS Trust.

Read More

Please read letter  from England’s Chief Midwifery Officer and National Clinical Director for Maternity regarding next steps following the publication of our first report on the 10th December 2020. 

Read Letter Here

Please read press release released on the 12th January 2021 from the Department of Health and Social Care concerning maternity leadership training following on from our first report published 10th December 2020

Read Press Release Here

December 2020

Baby Lifeline, the mother and baby charity, supports all recommendations made in today’s emerging findings report in to maternity care failings at Shrewsbury and Telford Hospital NHS Trust (SaTH).  

These ‘essential and immediate actions’ originate from The Ockenden Review’s preliminary analysis of  250 cases of concern, including the original 23 cases that led to the review.  A total of 1,862 cases will be considered by the review’s conclusion. 

Read more

SANDS statement following publication of the first report

It is shocking that so many babies have died at Shrewsbury and Telford Hospital Trust. We are here to offer bereavement support to all those parents and families affected, who will be going through unbearable pain following their loss”.

Read full statement from Clea Harmer, Chief Executive SANDS 

Actions in Donna Ockenden Review must be acted upon immediately by all maternity services say Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG)

Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden.

Read statement from RCM   
Read statement from RCOG 

Group B Strep Support’s response to Ockenden Review into maternity services at the Shrewsbury and Telford NHS Trust

Group B Strep Support has responded to the interim findings of the independent review of maternity services at Shrewsbury and Telford Hospitals (SATH) NHS Trust by a team led by midwifery expert Donna Ockenden, published today.

Read more 

Ockenden Report a shocking indictment of poor care at Shrewsbury and Telford, says Birth Trauma Association 

Today’s report from the Ockenden Review of maternity care at Shrewsbury and Telford Hospital NHS Trust makes for shocking reading. It is clear that good practice was frequently not followed. 

Read more 

Care Quality Commission (CQC) statement following the publication of the first report

Professor Ted Baker, Chief Inspector of Hospitals, said:  
“The death or injury of a new baby or mother is a devastating tragedy and something that everyone working in the health and care system must do all they can to prevent.   
“The emerging findings from Donna Ockenden’s review make for difficult reading. Limited oversight of risk, insufficient safety training for staff, poor communication with families, and a lack of robust investigation or learning when errors were made. Sadly, these are all themes that have been identified before, but yet again it has taken the repeated persistence of campaigning families and patients to bring them to the fore.  

“The continued national focus on the safety of maternity services is welcome – and we are seeing some positive change. However, the progress made does not yet meet the scale of the challenge.  

“As we set out in our Getting Safer Faster briefing earlier this year, there needs to be concerted national action and accelerated efforts to ensure that improvements in safety are achieved with the urgency required.  A major factor in this is the need to drive a change in culture that means the voices of staff, patients and their families are listened to and acted on. Without this shift we will not move forward. 
 “We welcome the recommendations set out by Donna Ockenden and her team and will monitor their implementation by the Trust, as well as working with the Department of Health and Social Care, NHS England/Improvement and wider system partners to play our part in supporting implementation. 

West Mercia Police statement following the publication of the first report 

Assistant Chief Constable for West Mercia Police, Geoff Wessell, said: “Our investigation is running concurrently to the Ockenden Review and we have had sight of the report that has been released today. 

“We are mindful that the families involved with the review have waited patiently for the initial learning actions outlined in the report. I want to reassure them, and the wider community, that our investigation will, in no way, impede the work of the Ockenden Review or prevent the actions outlined in today’s report from being implemented. 

“Our investigation into maternity services at the Trust remains ongoing and, as such, we are not in a position to release any further information at this time. When there is an update we can provide we will share this with the families involved first and foremost and then to the wider public.”

The Shrewsbury and Telford Hospital NHS Trust response to Donna Ockenden’s first report following the Independent Review of Maternity Services (10th December2020)

Link to video statement given by the Chief Executive

Minister of State for Patient Safety Nadine Dorries MP Statement: Publication of the findings of the Ockenden Review (10th December2020)

Link to video statement in Parliament 

Please read letter from Chief Executive, Executive/National Director and National Medical Director for NHS England and NHS Improvement regarding next steps following the publication of our first report on the 10th December 2020. 

Read Letter Here

Donna Ockenden appears before The Health Select Committee 15th December 2020

Today, 15th December 2020 as the Chair of the Independent Maternity Review at the Shrewsbury and Telford Hospital NHS Trust Donna Ockenden was asked to appear before the  Health Select Committee  at  The Houses of Parliament. Donna was invited to answer questions from the Select Committee on our first report published on Thursday. Donna’s piece runs from 0952hrs   to 1027 hrs  but before and after that there is some very interesting information on maternity services that may be of interest. 

Link to Parliamentlive.tv 

Today marks the launch of the first report of the independent review into maternity services at the Shrewsbury and Telford Hospital NHS Trust. The report outlines the local actions for learning for the Trust and immediate and essential actions for the Trust and wider system that are required to be implemented now to improve safety in maternity services for the Trust and across England.

Read the report here

November 2020

We now have a provisional date of the 10th December, subject to the Parliamentary timetable permitting,  for the first report into maternity services at the Shrewsbury and Telford NHS Trust (SaTH). This will be an emerging findings report and will include ‘Essential and Immediate Actions’,  as a result of our review of a selection of 250 cases of concern, which include the original 23 cases which initiated this independent maternity review.  The emerging findings report will include ‘Essential and Immediate Actions’ which we feel are necessary to ensure safe practice in maternity services at SaTH and will make a difference to the safe provision of maternity services elsewhere.

August 2020

Please see attached a news release announcing a new ’Improvement Alliance’ between The Shrewsbury and Telford Hospital NHS Trust and University Hospitals Birmingham NHS Foundation Trust.

Read News Release

July 2020

Press Release from Donna Ockenden


Donna Ockenden, Chair of the Independent Maternity review into care at The Shrewsbury and Telford Hospitals NHS Trust has confirmed today that the total number of family cases the review team is now looking into stands at 1862. 

Following an ‘Open Book’ review in 2018  which largely focused on electronic records, a call for families to come forward and a further search of paper records a further 496 families were identified to give 1862 cases.

“The Trust have worked closely with the review team throughout this process and have provided us with all requested information. I would like to thank them for all the work undertaken to reach this point.  By working together we have sadly identified a further 496 families as part of the review, who I am writing to this week.”

Families who wish to raise a concern about the care they have received, should do so directly with the Trust by contacting: sath.maternitycare@nhs.net or by phone to the Patient Advice and Liaison Service on: 01952 641222 extension 4382.

All efforts are now focusing on the completion of clinical reviews by the independent maternity review team to enable the final report to be published.  Donna Ockenden further explained: 

“it’s now really important that we focus our efforts on getting all clinical reviews completed so that we can make meaningful recommendations to improve services and give families the answers they have asked for.  We intend to have initial, emerging recommendations for maternity services published at the end of the year.

In order to give ourselves the time to write the final report, any new cases that come to light from now on will need to go directly to the Trust, for them to consider, rather than them coming to the maternity review team.”

These additional families will be written to telling them that their maternity care at The Shrewsbury and Telford Hospitals NHS Trust has been referred to the independent review team.  The letters to families discuss the Terms of Reference which explain the work of the Independent review team. The Terms of Reference can be found here:


The letters also provide information to enable families to make a choice as to whether they want their care to be reviewed by the independent team.   

Donna Ockenden finished by adding:

“I have made a commitment to the Secretary of State for Health and Social Care that we will undertake our work with the care and the independence it deserves and we will publish the final report as quickly as we can.  I want to assure families that their experiences are important to us and that our independent team of midwives and doctors continue to ensure that family voices remain central to everything we do.”

Background notes:

This Independent Maternity review was commissioned by Jeremy Hunt in 2017, when he was Secretary of State for Health and Social Care, following concerns raised by the parents of Kate Stanton-Davies who died shortly after birth in 2009 and Pippa Griffiths, who died just after she was born in 2016.

Emma Cotton 
Communications Officer
+ 44 (0) 7808 842 064
E: communications@donnaockenden.com 

July 2020 – Ockenden Review Open Letter

An open letter to the people served by The Shrewsbury and Telford Hospital NHS Trust 

I know that you, the communities of Shropshire, Telford & Wrekin and mid Wales care deeply about your local hospitals and the care we provide. All of us experience important life events in hospitals, from the birth of a loved one, to life-changing surgery or treatment in an emergency. You have a right to expect the very best care every time you use our services. However, if things do go wrong, it is the role of the Trust and our staff to learn from any failings, so that we can provide answers to families and patients and improve our care now and in the future. 

You will, of course, be aware that our Maternity Services have been under the spotlight for some time. I know that our standards of care have fallen short for many families and I deeply apologise for this. 

An independent review, led by experienced midwife, Donna Ockenden, is looking into cases involving families from our communities. Today, we know that the total number of families whose cases are being reviewed is 1,862. I recognise that this will be a huge concern, both for those families and everyone in our communities, who depend on us for their care. 

It is a concern for our staff too, who are committed to providing our patients with the highest standards of care. 

There is no doubt that this continues to be a difficult and painful experience for many families and I am truly sorry for their distress. I recognise that we should have provided far better care for each and every one of these families at what was one of the most important times in their lives. We know that we have let them down. 

I am very aware that, for these families, words will never be enough and what they want to see is evidence of real improvement at the Trust. This is why we are committed to listening to them and to working with Donna Ockenden’s Review to ensure lessons are learned and we have a service which the community and our patients can trust. 

We have made some progress in improving the standards of care for mothers and babies and the Care Quality Commission (CQC) now rates our Maternity Services as ‘Good’ across three of the five standards (Caring, Effective and Responsive). However, we are rated as ‘requires improvement’ for the other two standards (Safe and Well-led). We recognise that we still have a long way to go. 

One of the things we have learned is that we must be better at listening to everyone who uses our services. We will work harder at this and create more opportunities for families to tell us about their experiences, allowing us to make positive, clear and tangible improvements, based on what we learn. 

Our opportunity to listen and learn should not be confined to the families involved in the Ockenden Review. Any family not included in the review can come to us at any time to share their experiences or raise any concerns. You can contact us by email: sath.maternitycare@nhs.net or by phone to Patient Advice and Liaison Service on: 01952 641222 extension 4382. 

We must now let Donna and her team do their job and we will continue to work openly with them to help families get the answers they need and in turn for us to make the necessary improvements. 

In the meantime I want to reassure you that we are working hard to deliver the high quality Maternity Services that the people in our communities rightly deserve. 

Yours faithfully 

Louise Barnett 

Chief Executive, The Shrewsbury and Telford Hospital NHS Trust 

June 2020

Please see below a statement from West Mercia Police explaining more about their investigation and how it relates to the review. I hope this is helpful.

Statement from West Mercia Police:

“We appreciate that you may have questions about the police investigation and how this sits alongside the review and we’d like to give you as much clarity as possible.

We have been engaging with the Ockenden Review throughout and, following an assessment of the current information available, we now feel it’s appropriate to launch a police investigation to ascertain if any criminal offence has been committed.

The scope of our investigation (known as Operation Lincoln) is to identify whether there is evidence to support a criminal case either against the Trust or any individuals.

We are looking at cases from 1st October 2003, which is the date the current Trust was established. However, we will consider serious cases prior to this date and if you have any concerns at all we welcome you to contact us via this online form: https://mipp.police.uk/getForms/22HQ19D84-PO1/22HQ19D84-PF1

I want to reassure you that our investigation will not impede the progress of the Ockenden Review or the learning and health care improvements which they or the Trust may identify.

We are working with the Review to identify the cases that we believe are most likely to form part of the criminal investigation and we will be in touch with those families. This may mean we are not in touch with some of you but this shouldn’t be interpreted as your case being less important to us or the Review. Our investigation is to ascertain if a crime has been committed. To get to our investigative decision it is unlikely we will need to assess every case.   Again, however, if you have any concerns you can get in touch using the form linked above.

We cannot even begin to imagine what you have been, and continue to go through and we will endeavour to keep you informed as it progresses as best we can recognising the sensitivity of this nature of investigation.”

Press release from West Mercia Police

Investigation into maternity services and provision at Shrewsbury and Telford NHS Hospital Trust. Police statement regarding police investigation into maternity services and provision at Shrewsbury and Telford NHS Hospital Trust.

Read West Mercia Police statement | Read Donna Ockenden Press Release

Donna Ockenden is leading an independent maternity review into cases of serious and potentially serious concern at the Shrewsbury and Telford Hospitals NHS Trust and would like to hear from anyone who feels they have a potential case of concern or where they believe there are significant questions that remain unanswered.

Donna says: ‘My team and I will look into all potentially serious concerns around maternity care at the Trust that are brought to our attention. Every call and message is very important to us and one of the team will be in touch as soon as we can’.

To get in touch with the independent maternity review team please email Donna on:

We have just launched our website and social media channels keeping you up to date with the Maternity Review : ockendenmaternityreview.org.uk

Follow us on Twitter : twitter.com/OckReview

For families directly involved in the review connect to our private group on Facebook.

April 2020

Press Release from Donna Ockenden, Chair of the independent review of maternity care at Shrewsbury and Telford Hospitals NHS Trust advising families that progress continues during COVID-19.

Download Press Release

Press release from Powys Local Health Board

Please see below link to access the latest information from Powys Local Health Board in Wales on the Maternity review


PRESS ENQUIRIES: Emma Cotton/Anouk Curry Mobile: + 44 (0) 7808 842 064 Email: communications@donnaockenden.com

January 2020

Statement from Donna Ockenden, Chair of the independent review of maternity care at Shrewsbury and Telford Hospitals NHS Trust following the Adjournment Debate in the House of Commons on 15th January 2019:

“I am really grateful to the brave families who have contacted my Review team since my public appeal in November, bringing the total number of families to more than 900. My team are busy speaking to every family and hearing their story. Once again, I appeal to any family with concerns about the maternity care they received at Shrewsbury and Telford NHS Trust, and who has yet to come forward, to please do so by contacting 01243 786993.”

PRESS ENQUIRIES: Emma Cotton/Anouk Curry  Mobile: + 44 (0) 7808 842 064  Email: communications@donnaockenden.com

November 2019

The number of families who have contacted the independent review into maternity care at Shrewsbury and Telford Hospitals NHS Trust has increased. In light of this, Donna Ockenden has today finalised the revised terms of reference for the Review in agreement with NHS England, families and the Trust.

Read more

June 2019

The number of cases uncovered by a maternity review, led by Donna Ockenden at hospitals in Shropshire has more than doubled. In 2017, the then Health Secretary Jeremy Hunt announced the investigation, into avoidable baby deaths at SaTH, which runs Royal Shrewsbury Hospital and Telford’s Princess Royal. NHS Improvement has now asked for the total of deaths, still births and babies with brain damage since 1998. It said they were not necessarily the result of sub-standard care.

Read more