Ockenden Report: Neglect Found in Review of Maternity Services



Contact Us Today

Sign up to our newsletter

What is the Ockenden Report?

The Ockenden report was provided by Donna Ockenden following an independent review of maternity care at Shrewsbury Hospital due to concerns about safety in maternity services. The failings highlighted within the report demonstrate a number of issues faced by patients receiving treatment, caused by senior staff failures to follow clinical guidelines and listen to patients. The review was requested by Jeremy Hunt following efforts from the parents of infants who sadly lost their lives due to the shortcomings of staff.

The report includes experiences of 1,486 families between the year 2000 and 2019.

“Significant or major concerns” regarding the care which led to 131 stillbirths, 9 maternal deaths, 70 neonatal deaths, 29 cases of hypoxic ischaemic encephalopathy (HIE), and 65 cases of brain damage were identified within the Ockenden review.

The first report into the maternity scandal was released in December 2020, and the final report of the Independent Maternity Review of maternity services at the Shrewsbury and Telford Hospital NHS Trust has just been released.

In a Letter to the Secretary of State for Health and Social Care, Donna Ockenden stated that the hospital “failed to investigate, failed to learn and failed to improve, and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives.”

Main Issues Highlighted Within the Report

One of the main concerns highlighted within the Ockenden Report was the very low rate of c-section births. It was stated that the hospital’s obsession with “normal births” was a contributing factor to the overall failings of the trust. It was highlighted within the report that some women were forced to have vaginal births to keep surgery rates low, even when a C-section would have been a safer alternative.

The hospital still ranks sixth from the bottom of NHS England’s performance league table, showing a rate of 26.2 per cent of births being undertaken using c-section. Reviews of maternity services in Kent and Nottingham are currenly being undertaken.

Other issues identified within the report include:

  • Insufficient antenatal care for vulnerable women
  • Poor management of multiple pregnancies
  • Poor management of hypertension in pregnancy
  • Failure to recognise and treat unwell and deteriorating women
  • Reluctance to refer women for assessments for fetal abnormalities
  • Failure to act on abnormal heart patterns in fetus’s
  • Leadership and teamwork shortcomings


The conclusions within the Ockenden report were similar to those found within Bill Kirkup’s investigation in 2015  into shortcomings and failings at the Furness General Hospital maternity unit, Morecambe Bay. Identified within this report were poor risk assessments, an obsessive focus on “normal births” over c-section deliveries, poor working relationships and poor leadership and teamwork.


Recommendations Following the Report

More than 60 local actions for learning and 15 areas of immediate and essential actions to improve were recommended by the review team in light of the findings. Some of the 15 immediate and essential actions recommended within the report include the following:

  • “the need for significant investment in the maternity workforce and multi-professional training
  • suspension of the midwifery continuity of carer model until – and unless – safe staffing is shown to be present
  • strengthened accountability for improvements in care among senior maternity staff, with timely implementation of changes in practice and improved investigations involving families.”


The Importance of the Report

The outcome of this report has highlighted the need for change within the NHS to enable them to provide high quality medical treatment. Furthermore, it emphasises the importance of access to justice in all clinical negligence cases so that victims of this type of negligence can be justly compensated for their losses and, the NHS can be held accountable for their failings.


Clinical Negligence Claims Costs


The general rule of thumb in clinical negligence cases is that the NHS (or private trust) will be required to pay the costs of a successful claimant solicitor (or litigant in person)to a medical negligence case.

In order to recover the legal costs from a defendant, a bill of costs will need to be drawn up before proceeding with the process of detailed assessment.

Clinical Negligence costs claims are often substantial, and as such can be significantly contested by paying parties. ARC Costs specialise in recovering at least 50% of your costs as an interim payment in the early stages of dispute, and the majority of costs claims will resolve within 1 – 2 months of service of the Bill. If the claim is to be contested to a detailed assessment hearing, generally we will obtain 70% of the costs claimed as an interim payment on account, ensuring you can continue to fund other cases.


How can ARC Costs Assist?

Legal costs has become an increasingly complex area of law, particularly when significant sums are involved as can arise in clinical negligence disputes. We would always recommend input from a Costs Draftsman or Costs Lawyer is provided at the very outset of a claim for clinical negligence, to ensure that the retainer and hourly rates are in good order, and throughout litigation, to ensure costs budgeting is correctly forecasted.

We can further assist by preparing and negotiating your Costs Budget, which is critical to ensure maximum recovery on assessment. On conclusion, following preparation of the Bill of Costs we will assist in negotiating recovery of your outstanding fees. Managing your Costs Budget effectively is important, as you can recover up to 100% of all approved budgeted costs incurred.

To discuss your costs claim further, please do not hesitate to contact us on 01204 397302 or email one of the team using our email address: info@arccosts.co.uk. Alternatively, you may complete our online enquiry form and we will be in touch to discuss your query further on the same day.

Request Your Free Quotation

Contact us today for your free, no obligation quotation. Our team are on hand to help.


4 Bark Street East, Bolton, BL1 2BQ

01204 397302


Follow Us