The Ockenden review: a summary

The review team found a regretful pattern of poor investigations into a significant number of incidents with a harmful clinical outcome. The review found evidence of poor investigations into three significant cases which took place within less than a year of one another. This resulted in missed opportunities for learning and a lost opportunity to prevent further baby deaths from occurring at the Trust. This pattern remained the same throughout the periods investigated. It is highly concerning that the Trust was able to cover up these errors for such a long period of time.

Maternal death

In the 12 cases of maternal death, the review team considered that none of the mothers had received care in line with best practice, and in nine out of the twelve cases, significant or major concerns were identified. Internal investigations were poor, and only one external investigation was conducted. The internal investigations did not recognise system and service-wide failings to follow appropriate procedures. In some instances, women themselves were held responsible for the outcomes.

Stillbirth

In the 498 cases of stillbirth, one in four cases were found to have significant or major concerns that, if managed appropriately, might or would have resulted in different outcomes. Between 2011-19, 40% of the stillbirths reviewed did not have an investigation, again, missing opportunities for learning and preventing similar deaths that would occur in the future.

Hypoxic Ischaemic Encephalopathy 

In cases of Hypoxic Ischaemic Encephalopathy (HIE) – new-born brain injury caused by oxygen deprivation to the brain – care provided to the mother in 65.9% of all HIE cases was a significant and major concern.

Neontatal death

In cases of neonatal death, 27.9% of incidents reviewed were identified to have significant or major concerns regarding the maternity care provided, that might or would have resulted in a different outcome. Between 2011-19, a significant 43% of neonatal deaths were not investigated.  

Throughout this period, there were repeated failures to escalate concerns in both antenatal and postnatal environments, such as assessing the needs for emergency intervention during labour or providing proper and thorough investigations into the serious incidents.

The review team identified failings to follow national clinical guidelines such as fetal heart rate monitoring or resuscitation. This, alongside delays in escalation and failure to work collaboratively across disciplines, resulted in many poor outcomes experienced by mothers or their babies, resulting in injury and death.

Some causes of delay were owed to the culture among the workforce, noting a lack of action from senior clinicians and a ‘them and us’ culture between midwifery and obstetric staff which meant midwives feared escalating concerns to consultants. Significantly, many members of staff at the Trust were too scared to speak out about their experiences in fear of the repercussions. Some mothers also described the additional stress these interactions had on their own experiences.

The review also mentions repeatedly the lack of compassion expressed by staff. Examples include clinicians being unprepared for meetings, justifying their actions, and again, explanations that laid blame on the family themselves.

Systemic issues such as insufficient staffing and training gaps were also noted to be a significant issue in the operational running of the Trust. Staff were overstretched and overworked throughout the period with inadequate support from some senior members of the Trust. There is no doubt that this presented difficulties in being able to provide safe clinical care to their patients.

Regrettably, the review found that investigatory processes were not followed and more concerningly, the maternity governance team inappropriately downgraded serious incidents to avoid external scrutiny, successfully covering up the true scale of serious incidents at the Trust.

If an open and honest candour was adopted and resulted in appropriate investigations, it is almost certain that much fewer incidents would have occurred and those babies and their mothers would not have suffered the significant harm that they did. Instead, the same mistakes were repeatedly made, and the safety of mothers and babies was unnecessarily compromised as a result.   

As a result of the findings of the review, a significant number of 60 local actions for learning have been identified in a bid to improve the services provided at the Trust, and bring an end to the significant and constant failings. Some 15 areas across maternity services were also identified as requiring immediate and essential actions, to be implemented nationally. These include:

• 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 the present
• Strengthened accountability for improvements in cases among senior maternity staff, with timely implementation of changes in practice and improved investigations involving families

This is not the first time maternity services have been scrutinised. In fact, the poor maternity services provided in the UK are becoming an almost constant feature in weekly press. The government have recently introduced a range of measures and invested in staffing across the country, and whilst this is a welcome response, it is essential that continuous investment and improvements are made to ensure the safety of babies and mothers.

Our thoughts are with the families of loved ones injured, and to those who traumatically died as a result of the Trust’s failings. 

If you require any advice relating to this topic, please get in touch with our Clinical Negligence and Personal Injury team.