New National Maternity Report Echoes Lessons Identified in the Ockenden Review.

The publication of the Independent National Maternity and Neonatal Investigation's Final Report should serve as a stark reminder that the failings exposed in maternity services at The Shrewsbury and Telford Hospital NHS Trust were not unique.

Having represented families whose experiences formed part of the evidence that led to Donna Ockenden's independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, the findings of today's report are both deeply concerning and yet, entirely unsurprising.

For those of us who have spent years representing women and families whose lives have been devastated by poor maternity and neonatal care, today's report sadly comes as no surprise.

When Donna Ockenden published her report into the failings at The Shrewsbury and Telford Hospital NHS Trust in 2022, she exposed serious and systemic problems that had developed over many years. Her recommendations were intended not only to improve one Trust but to transform maternity care across the NHS.

Sadly, Baroness Amos’ national report demonstrates that many of the same themes continue to emerge across England. This is a horrendous national crisis.

The Independent National Maternity and Neonatal Investigation identifies recurring concerns around failures to listen to women, poor communication, inadequate staffing, weak leadership and governance, inequalities in maternity care, and a lack of learning when things go wrong.

These findings closely mirror the issues identified by Donna Ockenden, not only at Shrewsbury and Telford but also at Nottingham University Hospitals NHS Trust.

As I read this report, I was struck by how familiar many of its conclusions are. We are once again hearing about women not being listened to, concerns being dismissed, failures to identify deteriorating situations, a lack of escalation, workforce pressures, poor organisational culture and failures to learn from previous mistakes.

These are recurring themes. They are the same themes that bereaved families and injured mothers described at Shrewsbury and Telford and Nottingham.

Amos is categoric in her conclusion that there is absolutely no justification for the tragic cases of unsafe care and avoidable harm we continue to see. She is clear that urgent reform is needed.

Having read reports into maternity care spanning over a decade, I strongly believe that an unwavering and relentless commitment to change is now required. 

Reports do not save lives, implementation does.

We have now had a number of major maternity reviews, each identifying remarkably similar failings and making many of the same recommendations. Families are entitled to ask why change has not already been actioned and why incidents of avoidable harm continue to traumatise our country.

Whilst I welcome the publication of the report, the focus must now be on accountability and delivery.

No family should have to experience avoidable harm because lessons identified years earlier were not acted upon. Every recommendation in this report should now be treated as an urgent opportunity to prevent future tragedies rather than simply another piece of paper to acknowledge such.

The women and families I represent consistently say that they never want anyone else to go through what they have endured. The greatest tribute we can pay to them is to ensure that the lessons from Shrewsbury and Telford, Nottingham and now this national investigation, finally result in lasting change.

If you wish to speak to our specialist maternity team, please email: info@lblaw.co.uk or phone 0800 652 3371.