Shrewsbury and Telford Trust – Catastrophic failures and learning from the past

31 March 2022

The long-awaited review into maternity care at the Shrewsbury and Telford NHS Trust has finally been published and it makes for uncomfortable reading. Michael Clarke, Medical Negligence Solicitor in our PI team discusses the report’s distressing findings and looks at what happens next.

Yesterday, the results of a five-year long investigation into maternity services at Shrewsbury and Telford Hospital Trust were finally published. The Ockenden Inquiry, established in 2017 by the then Health Secretary Jeremy Hunt was led by expert senior midwife Donna Ockenden. Set up to look at cases of neonatal death, stillbirth, brain damage and maternal death the report spans practices by the trust over a 20-year period. Labelled the largest maternity scandal to be uncovered in the UK, the inquiry reviewed the maternity care and treatment of almost 1600 families.

Ockenden Review – The Key Findings
The key headline of the report is that with better care, around 201 babies might have survived, and other babies may have avoided life-changing injuries including severe brain injuries and cerebral palsy. In addition, 9 mothers would not have died needlessly during childbirth.

Other findings include;

  • A culture where mistakes were not investigated
  • Parents were not listened to when they raised concerns about the care that they had received
  • Where cases were examined, the responses were described as lacking ‘transparency and honesty’
  • Mistakes were not learnt from, leading to repeated and often almost identical failures in care
  • Caesarean sections were actively discouraged, often leading to subsequent issues and poor outcomes
  • The trust had a culture of bullying, anxiety, and fear of speaking out amongst staff that remains to this day

The 250-page report outlined how a toxic culture was allowed to persist at the trust for decades, leading to tragedy after tragedy

Ockenden Review – Learnings for the Shrewsbury and Telford Trust

Shrewsbury and Telford Trust have been handed 60 local actions for learning, considering the care received by 1,486 families.

These actions include;

  • Improving the management of patient safety incidents
  • Involving patients and families in investigations
  • Providing support for staff so that concerns can be raised
  • Improving complaints handling, guidelines and audit processes
  • Care of vulnerable and high risk women
  • Multidisciplinary working
  • Providing safe staff levels, including anaesthetic staff
  • Supporting staff after the review is published

Ockenden Review – Next Steps
In addition to the local actions for learning, there were 15 immediate and essential actions to improve care and safety in maternity services across England including;

  • Workforce Planning and sustainability with minimum staffing levels to be agreed nationally and a robust training programme to be implemented for newly qualified midwives (NQMs)
  • Escalation and accountability with staff able to escalate concerns if necessary
  • Learning from maternal deaths, with all maternal post-mortem examinations conducted by an expert in maternal physiology and pregnancy-related pathologies
  • Multidisciplinary training with staff attending regular mandatory training
  • Bereaved families must be provided with appropriate bereavement care services
  • Investigations with families and staff must look at lessons learned and changes must be implemented in a timely manner

The report’s findings, coupled with these actions will no doubt provide an opportunity for many other Health Boards and Trusts across both England and Wales to review their own standards of maternity care.

Of the report and its findings, Donna Ockenden, Chair of the review said;

“It is absolutely clear that there is an urgent need for a robust and funded England-wide maternity workforce plan starting right now, without delay, and continuing over multiple years.

“This is essential to address the present and future requirements for midwives, obstetricians, anaesthetists, neonatal teams and equipment, and all the associated staff working in and around maternity services.

“Without this very significant multi-year investment, maternity services cannot provide safe and effective care for women and babies.

“We now know that this is a trust that failed to investigate, failed to learn and failed to improve”

“This resulted in tragedies and life-changing incidents for so many of our families”

For the families involved in the inquiry, the findings will be bittersweet. Whilst it will not change what happened, we hope that it will give them some comfort that they have finally been heard following a lengthy campaign to learn the truth about why their babies, and many others, died.

Sadly, whilst the Shrewsbury and Telford Trust investigation has been labelled the biggest maternity scandal in the UK, it is certainly not the first investigation into the standards of maternity care in England and Wales.

In 2013 the Morecombe Bay Inquiry founded a culture of collusion, denial and incompetence, with an insistence by midwives to pursue natural childbirth. In 2021 it was revealed that there were multiple deaths and more than 130 babies suffered brain damage as a result of being starved of oxygen at birth at East Kent Hospitals Trust over a four-year period. In October of the same year the Maternity Services Oversight Panel (IMSOP) presented their findings following a review of stillbirths at the former Cwm Taf University Heath Board and a further report in January 2022 following a review of neonatal services provided at Prince Charles Hospital in Merthyr Tydfil.

Here at Redkite Solicitors we can provide specialist advice if you or your family have experienced loss or life-changing injuries because of maternal negligence. We offer a free initial consultation and discussion so please get in touch if you have been affected.

Get in touch

Whilst we cannot change what has happened, we can work with you to get answers and to ensure that no other family has to go through a similar experience.

Please call Michael Clarke, Medical Negligence Solicitor on 07792 052 493 or email

The contents of this article are intended for general information purposes only and shall not be deemed to be, or constitute legal advice. We cannot accept responsibility for any loss as a result of acts or omissions taken in respect of this article.