The Ockenden Review: A stark reminder of the work to be done to make maternity safer

A Blog by Sara Ledger, Head of Research and Development at Baby Lifeline


Yesterday saw the long-awaited publication of the Ockenden Review, and whilst the findings were sadly not surprising or new, the content was harrowing.

What is the Ockenden Review?

Following a letter from bereaved families raising concerns of babies and mothers who died or potentially suffered significant harm whilst receiving maternity care at Shrewsbury and Telford Hospital NHS Trust (SaTH), a review was commissioned by then Secretary of State for Health and Social Care, Jeremy Hunt. The publication of the first part of this review looked at the first 250 cases of maternal and neonatal harm between 2000 and 2019; including cases of stillbirth, neonatal death, maternal death, severe brain damage in babies, and other severe complications in mothers and newborn babies.  

Repeated Recommendations

The Ockenden Review’s recommendations are not new – they mirror recommendations made before it, almost exactly in some cases.

Those who work together should train together.”Better Births, 2016

Staff who work together must train together.” – Ockenden Review, 2020

Baby Lifeline’s Mind the Gap reports have shown that, despite recommendations for training, there are detrimental gaps in important areas shown to link to avoidable harm. For example, the leading cause of death in pregnancy and up to 6 weeks after was heart disease from 2015-2017 – being the cause of death for almost 1 in 4 mothers who died. Despite this, when we looked at training offered to health professionals on the frontline, the training was provided in around a third of hospitals in 2017/18.

Similarly, when we surveyed whether staff who worked together trained together, we found that even topics like skills and drills training were not attended by all professional groups caring for mothers and babies across many units. Obstetric anaesthetics were not mandated to attend in around a third of trusts, for example.

The Review demonstrates many examples where staff were clearly not competent in important areas, and mothers and babies suffered as a result. This is a systemic failure and is not unique to this trust.


There are so many amazing initiatives all over the country, designed to actively improve care for mothers and babies, and to ultimately save lives. The Saving Babies’ Lives Care Bundle, for example, is evidence-based best practice guidance to reduce stillbirth and neonatal deaths. When we looked at just the training elements of the Saving Babies’ Lives Care Bundle we found that fewer than 8% of trusts were providing the training necessary to implement the bundle locally.

Trusts stated that the biggest barriers to providing and attending training were lack of funding and staff shortages.

What Now?

Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change.”  – Ockenden Review, 2020

The Ockenden Review is yet another opportunity to get this right, for all mothers and babies – we cannot get this wrong again. We cannot keep paying lip-service to these reports and not fully and properly investing in their recommendations. I have outlined just a few examples in a small pool of recommendations and ineffectively implemented solutions – it’s time to act, properly.

Baby Lifeline will keep pushing for change, with a strong focus on The Review’s 7 essential and immediate actions for all maternity units:

  1. Enhanced safety through increased partnerships and networks
  2. Listening to women and families
  3. Staff training and working together
  4. Managing complex pregnancies better
  5. Risk assessment throughout pregnancy
  6. Monitoring fetal wellbeing
  7. Informed consent for women

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