Shropshire baby deaths: Ockenden report delayed until March

A major review investigating hundreds of cases in which mothers and babies may have been harmed has been delayed until March 2022.

Senior midwife Donna Ockenden has been looking at services at Shrewsbury and Telford Hospital NHS Trust (SaTh) and her findings had been due in December.

The delay follows the recent emergence of “very substantial information”, she told families.

SaTh said it was co-operating fully with the review team.

It added that most of the actions raised in an interim report had already been completed.

Ms Ockenden’s team is examining 1,862 cases and is thought to be the largest ever review of maternity care in the NHS.

Her interim report published in December 2020 found some mothers were blamed for their babies’ deaths.

“We are clearly very concerned about how this has happened, but it’s clearly
very important information… so I am glad it has been uncovered and it can now be
considered in full light of the review.”

‘Right thing to do’

In a letter to families this month, Ms Ockenden said her team had received the new information from the hospital trust “over the summer months and right up to the end of September” and once it was decided the documents were important, contacted Health Secretary Sajid Javid to ask for more time.

“My team and I all believe this was absolutely the right thing to do. I hope that you all agree with us,” she wrote.

Ms Ockenden was asked to review maternity services at SaTh in 2018 following a campaign by two families who lost their baby daughters.


Donna Ockenden

Image source, Ockenden Review

Richard Stanton and Rhiannon Davies’s daughter Kate died hours after her birth in March 2009, while Kayleigh and Colin Griffiths’s daughter Pippa died in 2016 from a Group B Streptococcus infection.

Ms Davies told BBC News that following the emergence of the new documents, families had written to Mr Javid and former health secretary Jeremy Hunt to ask how the information could have been “mislaid and then happened upon” by SaTh.

She said the documents were thought to be “hundreds of files relating to hundreds of cases” that were already under review and added that “it smacked of incompetence at best”.

“We are clearly very concerned about how this has happened, but it’s clearly very important information… so I am glad it has been uncovered and it can now be considered in full light of the review,” she said.

The delay was “not ideal”, but she said the families agreed the review was a “once-in-a-generation opportunity to learn from hundreds and hundreds of cases of avoidable harm, therefore it has to be done right”.

She was pleased with the current progress of the review team, she added, but questioned the leadership team at the hospital.

The vast majority of cases being investigated are since 2000.


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Analysis box by Michael Buchanan, social affairs correspondent


This delay is in part a reflection of the sheer scale of the inquiry.

Donna Ockenden’s team were originally asked to look into 23 cases; they’re now investigating 1,862, the largest ever inquiry into a single service in the history of the NHS.

The new publication date will be about five years after the inquiry was commissioned and perhaps unusually however, I’ve not picked up any complaints from the dozens of families I’ve spoken to about the length of time its taking.

That’s probably due to the fact that many families have been asking questions for years anyway.

But it’s also to the credit of Donna Ockenden, who is repeatedly praised by those families for her sensitive handling of the inquiry, and her willingness to regularly communicate with them.

But even when Ockenden reports, that won’t necessarily be it – West Mercia Police is also investigating the trust and are likely to be doing so for two or three more years.


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Updating an NHS England board meeting on Thursday afternoon, Deputy Chief Medical Officer Aidan Fowler said the Ockenden team had approached the secretary of state for more time after “further papers were forthcoming from the [hospital] trust”.

He said a reply from minister Maria Caulfield confirmed the extension and the trust was now working towards a 24 March deadline.

Supporting board papers said funding had been provided for the trust to accelerate the recruitment and development of the maternity support workforce and there had been further investment in midwifery advocates, who provide educational and psychological support for midwives.


Rhiannon Davies


Regional leadership had also been strengthened, with the majority of regional obstetricians and deputy regional chief midwives’ roles now filled, they said.

Almost a year on from the interim report in December, the hospital board must review its own progress in their public meetings, NHS England said.

The board acknowledged the risk from Covid-19 could hamper progress while it would also take time for the extra funding to make a difference.

In a statement, Hayley Flavell, director of nursing at the hospital trust said it was aware of the new timescale and had made progress with introducing new ways of working.

“Alongside this, we will continue in our work to implement in full the measures set out in the first report, where we have made strong progress and have already completed over 60% of the actions, and we will address any new actions raised in the final report with the same focus and resolve we have brought to the initial recommendations,” she said.

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