Statement on Ockenden review of maternity services

Madam Deputy Speaker, with permission I’d like to make a statement on the initial report from the Ockenden Review, which was published this morning.


Before I update the House on the findings, I’d like to remind the House of the tragic circumstances in which this review was established.

It was requested by the government following concerns raised by 2 bereaved families in December 2016 whose babies had sadly died shortly following their birth at the Shrewsbury and Telford Hospital NHS Trust.

I am grateful to my Right Honourable friend, the member for South West Surrey, who, as Secretary of State, asked NHS Improvement to commission this independent inquiry.

The inquiry is chaired by senior registered midwife, Donna Ockenden, a clinical expert in maternity, who was tasked with assessing the quality of previous investigations, and how the trust had implemented recommendations relating to newborn, infant and maternal harm.

As this report acknowledges, this year this country has rightly united in pride and admiration for our NHS.

But we must also accept that in the past, not everyone has experienced the kindness and compassion from the NHS that they’ve deserved.

The review team has met face to face with families who have suffered as a result of the loss of brothers and sisters, or, from a young age, have been carers to profoundly disabled siblings.

And they have also met parents where there have been breakdowns in relationships as a result of the strain of caring for a severely disabled child, or suffering the grief after the death of a baby or resultant complications following childbirth.

Madam Deputy Speaker, the original terms of reference for the review covered the handling of 23 cases.

However, since the launch of this review, more families have come forward and extra cases have been identified by the trust.

As a result, the review is now covering 1,862 cases, which has led to an extension of the review’s scope and delivery.

So an interim report has been published today, containing a number of important themes, which the review team believe must be shared across all maternity services as a matter of urgency.

Indeed, Madam Deputy Speaker, I myself personally pushed, and the government pushed to have this interim report at this point in time so that we could learn from what had happened so far in terms of the findings of the inquiry.

This is the first of 2 reports, based on a review of 250 cases between 2000 and 2018.

A second, final report will follow next year.

Today’s report makes clear that there were serious failings in maternity services at the Shrewsbury and Telford Hospital NHS Trust.

I’d like to express my profound sympathies for what the families have gone through.

There can be no greater pain for a parent than to lose a child. And I am acutely aware that nothing I can say today will lessen the horrendous suffering that these families have been through, and continue to suffer.

However, I would like to give my thanks to all the families who agreed to come forward and assist in this inquiry. The team held conversations with over 800 families who have raised serious concerns about the care they have received.

I know that it has not been easy for them to revisit painful and distressing experiences.

But through sharing their stories, we can ensure that no family has to suffer the same pain in the future.

From the outset the inquiry wanted families to be central to the team’s work, and for their voices to be heard.

And I am pleased that the families were able to see the report first, this morning, shortly before it was presented to Parliament.

I can assure them, and members of this House, that we are taking today’s report very seriously, and that we expect the trust to act upon these recommendations immediately.


Madam Deputy Speaker, I’d like to thank Donna Ockenden and her team for their diligent work. Their valuable work provides a series of ‘essential and immediate’ actions to improve patient safety, and to make sure that maternity services at the trust are safe.

Four of these actions are for the trust, and 7 for the wider maternity system as a whole.

The report sets out clear recommendations for what the trust can do to improve safety relating to overall maternity care, maternal deaths, obstetric anaesthesia and neonatal services.

The report also sets out actions that can make a difference to the safe provision of maternity services everywhere.

This includes recommendations for enhancing patient safety, how we can best listen to women and families, developing more effective staff training and ways of working, managing complex pregnancies and risk assessments throughout pregnancies, monitoring fetal wellbeing, and how to ensure patients have enough information to make informed consent.

I welcome these recommendations, and the other recommendations in the report.

And we will be working closely with NHS England, NHS Improvement, and Shrewsbury and Telford Hospital Trust, who have accepted and will take each of these recommendations forward.

So we learn from these tragic cases, and so we can give patients the safe and high-quality care that they deserve.

Madam Deputy Speaker, patient safety is a big priority for me and for this government.

We want the NHS to be the safest place in the world to give birth, and this report makes an important contribution towards that goal.

Our ambition is to halve the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries in babies occurring during or soon after birth, by 2025.

And we have already achieved early our ambition for a 20% decrease in stillbirths by 2020.

But of course there is always more to do.

And we owe it to the families to get it right.


Madam Deputy Speaker, the Ockenden Review is an important document, vividly showing the importance of patient safety.

I can assure the House that we will learn the lessons that must be learned, so the tragic stories found within these pages are never repeated.

I commend this statement to the House.

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