Summary of findings from the Ockenden Review of the Shewsbury and Telford Hospital NHS Trust

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The following provides a summary of the findings of the Ockenden Review of the Shewsbury and Telford Hospital NHS Trust which was released on 30th March 2022.

The review, led by Donna Ockenden, examined cases involving 1,486 families and 1,592 clinical incidents. The review found that 201 babies and nine mothers could or would have survived if they had received better care.

In summary, the review is

about an NHS maternity service that failed. It 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.”

The findings echo those detailed within Morecambe Bay Investigation (2015) into maternal deaths, and the Savita Halappanavar Patient Safety investigation (2013), both of which HCI included as part of our research paper “The Healthcare System: Will We Ever Learn? Review of the common themes arising from UK and Ireland healthcare inquiries”.

Findings of the Ockenden Review include:

Patterns of repeated poor care

Failure in Governance and Leadership

Poor internal investigation into serious incidents

Poor overview by external bodies

How can HCI Help?

National and international investigations into failings in the healthcare sector are continually ongoing. It was evident from HCI’s Research Paper The Healthcare System: Will We Ever Learn?, that time and again, similar system failings have led to similar patient outcomes, with the recommendations to address these outcomes often mirroring previous reports. It is imperative that providers of care reflect on the findings of these investigations to apply system-wide learning for the benefit of all service users.

If you require support in this area, HCI can conduct an independent audit of your service against the findings identified in investigations such as the Ockenden Review of the Shewsbury and Telford Hospital NHS Trust. This will help you implement the learnings from the inquiries, reduce potential risks and improve the overall quality and safety in your service.

Further Information

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