Ockenden (Shrewsbury)

The **Ockenden Inquiry**, also known as the **Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust**, was a thorough investigation led by **Donna Ockenden**. This inquiry was initiated in 2017 in response to numerous reports of severe failings in maternity and neonatal services at the Trust, covering cases predominantly between **2000 and 2019**. The inquiry aimed to uncover the extent of the issues, understand their causes, and provide recommendations to improve maternity care across England.

The inquiry uncovered a shocking array of failings within the Trust. It found that many mothers and babies had suffered harm due to poor care practices, lack of effective communication, and a culture of denial and cover-up. In total, the inquiry identified at least **201 cases** where better care might have prevented the deaths of mothers or babies. These cases highlighted a pattern of substandard care, including failures to recognize and respond to fetal distress, inappropriate use of drugs to accelerate labor, and a lack of proper monitoring and timely interventions.

A significant aspect of the inquiry's findings was the inadequacy of the Trust's response to incidents of poor care. There was a pervasive culture of defensiveness and a reluctance to investigate and learn from mistakes. The report criticized the leadership and management at the Trust for failing to create a safe and supportive environment for both patients and staff. It also highlighted the insufficient oversight by regulatory bodies, which failed to detect and address the problems in a timely manner.

The **Ockenden Inquiry** made **15 Immediate and Essential Actions (IEAs)**, which were recommendations aimed at improving maternity services not only at the Shrewsbury and Telford Hospital NHS Trust but across the entire NHS in England. These recommendations focused on ensuring safer staffing levels, enhancing training for maternity staff, improving the oversight and accountability of maternity services, and promoting a culture of openness and learning. The inquiry emphasized the importance of listening to and involving families in their care and decision-making processes.

The impact of the Ockenden Inquiry has been profound, leading to significant changes in policies and practices within the NHS to enhance the safety and quality of maternity care. The findings and recommendations underscored the urgent need for systemic improvements to prevent similar tragedies in the future and to restore public confidence in maternity services.

**In one sentence**: The Ockenden Inquiry was an independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, identifying widespread failings and making 15 Immediate and Essential Actions to improve maternity care across England.