Maternity services in crisis: the Ockenden Review and its consequences

In March 2022, the Ockenden Review was published following a review of the injuries and deaths of 1862 mothers, infants and babies at Shrewsbury and Telford Hospital NHS Trust. Sophie Fox, Senior Associate solicitor who specialises in Clinical Negligence, looks at the outcomes of this report and asks whether maternity services across the country are in crisis, with such incidents demonstrating failures in the levels of care provided.

The Review found that the Trust “failed to investigate, failed to learn and failed to improve, and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives.”

Stillbirth and Serious Injury

In my experience as a Clinical Negligence solicitor, I have dealt with several cases of stillbirth late in pregnancy, and serious injury caused to baby as a result of negligent management of pregnancy and birth. It is frustrating to see the similarities in the cases investigated by the Ockenden Review.

All too often in stillbirth cases, mum has concerns about reduced foetal movement and seeks advice, only to be told it is normal to expect baby to be moving less during the later stages, and to be reassured everything is fine. However, it is not normal for foetal movements to reduce: it can be a sign the baby is struggling, and delivery may need to be expedited.


Similarly, the number of times symptoms of pre-eclampsia are not acted upon is disappointing. Headaches, swelling and high blood pressure should all indicate that a urine test needs to be performed.  If this shows traces of protein, there is a high risk of pre-eclampsia and action needs to be taken, or both mother and baby’s lives could be at risk.

In instances where these often simple-to-spot symptoms are overlooked, it can lead to the very worst happening and the death of baby in utero followed by the trauma of delivering a stillborn baby.

Delays during labour

Where death is avoided but there are delays during labour such as failure to act on signs that the baby is in distress and/or to expedite delivery or perform a timely caesarean section, babies can sustain ischaemic hypoxic encephalopathy (simply put, lack of oxygen to the brain) causing life-long and life-limiting conditions such as cerebral palsy. This can leave what would have been a healthy baby needing assistance in all aspects of life, including reduced or no mobility, enormous and complex therapy, care and accommodation needs and a vast range of other difficulties, including epilepsy and developmental delay.

Neonatal care

In the new-born period, failings in neonatal care can lead to a host of other injuries with life-long implications, for example, the failure to diagnose and treat jaundice resulting in hyperbilirubenia, which can cause brain injury similar to cerebral palsy.

Each case is distinct and must be investigated on its own merits, but I have found in many cases mum had a feeling something wasn’t quite right, sought help, and then was wrongly – or falsely – reassured.  Too often parents are made to feel as though they are a nuisance, that they are being overly anxious, or that they don’t know what they are talking about. In reality, mums know their own bodies and their concerns should be listened to and appreciated.

Impact and consequences of failures

The impact of these failures can leave women harbouring intense feelings of guilt. Many of the mums we hear from fear that they are somehow to blame for what happened to their child: for not making themselves heard, for not being able to bear the pain, for not being able push harder, for having an infection that they have passed to the child, when nothing could be further from the truth.   This can lead to serious psychiatric injury, a fear of hospitals, and in some cases the impact is so severe that they do not feel able to have any more children and to complete their family.

Maternity services crisis

It is important to recognise that this is still a minority of cases and that most pregnancies and deliveries in the UK occur with a good standard of care.  It is also possible for injuries to occur without anyone being at fault. In some instances, issues do arise due to a combination of poor funding, low staffing levels, and high-pressure environments, resulting in families not receiving the levels of care that they are entitled to.  However, from my experience it is not only hospitals in Shrewsbury and Telford that have these problems.

This is not the first major review of maternity care in the UK; similar reviews have taken place at Pennine Acute Hospitals Trust and other Trusts in the past, which have highlighted the same failings, yet the issues are still occurring.

Hopefully, the publication of the Ockenden Review will lead to true change and an improvement in care, leading to a decrease in the incidences of stillbirth and birth injury.

If you are concerned about the care you received during your pregnancy, please get in touch today. We are here to help you.