The Ockenden Review: What You Need to Know
The final report of the Independent Review of Maternity Services published in March 2022, also known as the Ockenden Review, exposes the extensive systematic maternity failures demonstrated by Shrewsbury and Telford Hospital NHS Trust. Building on the findings from the first report in December 2020, this final report raises more focal learning points, action points, and further calls on areas for improvement.
Revealing a maternity service that essentially failed to safeguard mothers and their babies, this is an example of an NHS trust, like many others across the country, that neglected to learn from clinical mistakes, leading to devastating yet avoidable maternity outcomes.
Whilst the Ockenden review provides 60 recommendations for Shrewsbury and Telford trust, it also identifies immediate and essential actions that must be embedded in all maternity systems across England to drive improvements in safety, quality of care, patient experience, and prevent the avoidable harm that results from poor care across maternity and neonatal services.
Moving forward, the 4 key pillars that ought to form the foundation of NHS trusts’ maternity services include:
- Safe staffing levels
- A well trained workforce
- Learning from incidents
- Listening to families
If all of these are implemented timely and effectively they will serve to accelerate improvements in maternity safety provision across the NHS.
Why is this report so important?
Patient experience and patient safety are both key priorities for the NHS whilst it faces mounting pressures and a 25-year low in public and staff satisfaction. The significance of excellent patient safety provision is illustrated in the wider NHS Patient Safety Strategy and its initiatives, including the new Patient Safety Incident Response Framework.
Despite a greater national focus on maternity safety of late, studies show that maternity services are not meeting safety and quality of care standards - fundamental aspects that should be fixed at the heart of every maternity service. For example, a 2022 CQC report demonstrates that maternity care was found to be substandard at 39% of maternity units investigated in England.
On top of this, the cost of poor maternity care to the NHS is incredibly impactful. Analysis of NHS maternity units shows that maternity failings amounted to £65 million in compensation payouts over the last decade.
With these figures in mind, the Ockenden review has come at a critical time and is vital if services seek to drive significant improvements in the delivery of safer maternity care and avoid low CQC inspection ratings, or even fines.
Action to improve maternity care and safety in maternity services is imperative and must be implemented straight away, with clinical teams across disciplines working together to bring about effective and long-lasting change, ensuring women and babies are protected during one of the most important and vulnerable times in their lives.
Maternity services across England must carefully consider the recommendations raised in the Ockenden report amongst other relevant national guidance pertaining to NHS patient safety requirements and standards, such as the three year delivery plan for maternity and neonatal services.
The Ockenden review exemplifies part of broader, deep-rooted issues occurring in maternity and general patient safety practice, which brings us onto the next point.
If you’d like to learn more about meeting national maternity safety standards, register to our one-day Improving Maternity Safety Standards and Quality of Care online training, led by Dr Marie Lewis, Independent Healthcare Improvement Consultant & Consultant Midwife.
Learning outcomes include:
- Exploring lessons learnt from national maternity reviews and investigation such as Ockenden and Kirkup
- Learn innovative approaches to enhance multi-disciplinary training
- How to achieve more personalised and more equitable care with a view to ensure the continuity of care
- Develop consistent and clear maternity leadership to improve quality of safety oversight
- Understand the change and action needed to improve outcomes for women and babies from black and minority ethnic groups
- Develop an action plan to embed sustainable and safe staffing levels within your maternity unit in order to achieve safe staffing by 2027-8