It has been a tough week for patients.

The final report from Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust – the Ockenden Report – was unflinching in its criticism of the atrocious clinical care families experienced and the gaslighting of patients who tried to get answers for why their babies had died or been left disabled.

As mothers, we’ve both been strongly affected by the patient stories in the Ockenden Report. Not just the individual tragedies but also the trust’s total lack of compassion while caring for patients and when they were trying to get answers about what went wrong.

Blaming patients

We want to pay tribute to two mothers Rhiannon Davies and Kayleigh Griffiths whose determination to get answers for why their daughters had died, led to the enquiry. Thanks to them, other patients affected by sub-standard care at the trust know they are not to blame for the deaths of their children. As the Ockenden Report makes clear, the trust had a habit of blaming mothers when things went wrong.

But all the families that Ockenden heard from – and there were nearly ,1500 – have done a great service to all patients: the Ockenden Report is clear about the reasons things went wrong and explicit in what must change in all maternity units in England. We support the report's findings and look to leadership within NHS England to ensure desperately needed changes are made in maternity care.

As Donna Ockenden, the midwife chair of the enquiry, wrote in her report: “Even now, early in 2022 there remains concern that NHS maternity services and their trust boards are still failing to adequately address and learn lessons from serious maternity events occurring now…However, it is our belief that if the ‘whole system’ underpinning  maternity services commits to implementation of all the Immediate and Essential Actions within this report with the necessary funding provided then this review could be said to have led to far reaching improvements for all families and all NHS staff working within maternity services.”

Take action

So we welcome the Secretary of State’s response to the report and his statement that: “It’s vital that across maternity services that we focus on safe, personalised care where the voice of the mother is heard throughout.” But we have heard similar pledges before and already, the current chief executive at the Shrewsbury and Telford Hospital NHS Trust, has said the trust “will take action where we deem them appropriate”.

This is not the expectation of the report. Donna Ockenden made it clear when she presented the report that the list of local actions for learning for the trust and immediate and essential actions for all maternity units in England were “not nice to haves or maybes, these are must dos”. It is hugely disappointing for us, and must be devastating for the families involved, to hear the chief executive be evasive about changes that will improve a maternity unit where there were 131 stillbirths, 70 neonatal deaths and nine maternal deaths linked to failings in maternity care. The impact on the families of the loss of a baby and a mother is devastating. The families who contributed to the review need the trust’s commitment and the NHS’s to implement these changes.

A failure to learn lessons and make changes has characterised the NHS’s response to many investigations into failings in care over the years. The Ockenden Report calls for major investment in training and staffing of maternity units, but more staff is just one requirement to improve safety.

Culture change

We need to see a cultural change within the NHS. The Ockenden Report found that patients had not been listened to, as has nearly every recent enquiry into unsafe maternity care. It is high time healthcare professionals listened to patients, found out what is important to them, and worked in partnership with them to deliver safe and effective care.

Such partnership working may be able to reverse the public’s dissatisfaction with the NHS, which is at a 25-year low, according to the latest British Social Attitudes survey, also out this week. The survey’s authors describe the findings as “the most extraordinary set of results we have seen” and the BMA, the doctors’ union, said the findings were unsurprising since they were “a direct consequence of a service which has been pushed to the edge of collapse with severe deficit – in staffing, in beds, in community services, in facilities, and in equipment”.

While we agree that the NHS is under resourced and understaffed – and the public does too in the BSA survey – staffing is not the only issue behind patients’ discontent. At the start of the lockdown, the NHS made wholesale changes to the provision of services, without any discussion with patients. This led to a huge disruption between patients and the NHS, and it is this, we believe, we’re seeing reflected in the BSA survey.

Major disruptions

We saw this change in attitude coming as early as autumn 2020 following our first pandemic patient experience survey. Back then we warned of “major disruptions to the relationships between the patients and the health and care services they rely on”.

Claims by the NHS and Government that the NHS has ‘done brilliantly’ throughout the pandemic, jar with patients’ experiences. We know NHS staff worked tirelessly and many are now burnt out, as the annual NHS Staff Survey, also out this week, makes clear. NHS workers themselves are concerned about patient safety, with two fifths saying they didn’t think their organisation would act if they raised a concern about clinical safety. This is what Ockenden found in Shropshire and Telford, staff terrified to raised concerns about patient safety.

Honesty and transparency

Patients know things in the NHS are now really very difficult. And patients would like a little more honesty and transparency about the situation. Earlier this year we called on the NHS to recognise the extent of patient difficulties, understand them, and make a concerted effort to find out patients’ concerns. If patients' confidence and satisfaction in the NHS are to improve, the service must reconnect with patients and work in partnership with them to rebuild a relationship that has been badly disrupted so that together, the NHS and patients can redesign services.

We know this won’t be easy. It will take a cultural change within the NHS, and a workforce ready to make that change. The NHS staff survey found staff morale in NHS England at its lowest since 2017 and almost a third often think about leaving the organisation. Despite this, the proposed amendment to the Health and Care Bill that the Secretary of State publish a report describing the system in place for assessing and meeting workforce needs every two year was defeated this Wednesday in the House of Commons.

Healthcare workers in organisations lacking enough staff, whose morale is so low they want to quit their jobs, will not be able to provide compassionate, safe care. The Ockenden Report noted that poor morale, a chaotic organisation, and staff frightened to speak up all played a part in the unsafe care provided in the maternity unit at the Shrewsbury and Telford NHS Trust.

Patient partnership

As we reflect on this week, it seems self-evident to us that health and care services must make the health and well-being of patients their priority and work in partnership with patients and carers. To be able to do this, services need well-trained staff, supported by management and colleagues, working in properly equipped facilities.

Nothing can bring back the babies and women that died because of catastrophic failings at the Shrewsbury and Telford NHS Trust, or undo the damage caused to so many other patients. But we hope that the immediate and essential actions in the Ockenden Report are implemented in all English maternity units and that other services recognise the need to change health service culture to one that listens to patients, investigates when things go wrong in an open and transparent manner, and treats patients with compassion and kindness.


Lucy Watson              Rachel Power
Chair                         Chief Executive
          Patients Association