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RCOG response to Ockenden review leak

News 20 November 2019

A leaked status update on an independent maternity review into cases of serious and potentially serious concern at the Shrewsbury and Telford Hospitals NHS Trust (SaTH) has been published by the Independent and subsequently other media outlets. The RCOG is referenced in this leaked document as it was asked by SaTH to assess its maternity and neonatal services in 2017 in light of reports of poor care.


A spokesperson from the Royal College of Obstetricians and Gynaecologists, said:

“The death of every mother and baby is a devastating tragedy and we offer our heartfelt condolences to any family that has suffered such a loss.

“Following a CQC review, in July 2017 the RCOG were commissioned by Shrewsbury and Telford Hospital NHS Trust (SaTH) to assess their maternity services of as part of a non-regulatory and advisory review. The review was conducted by an independent team of assessors with expertise in maternity care and safety, in line with The Academy of Royal Medical College’s framework of operating principles for managing invited reviews within healthcare.

“The review was commissioned to focus on the current maternity and neonatal practice at the time following concerns over higher than average perinatal mortality rates. The review did not focus on individual deaths retrospectively - these were the focus of other independent investigations.

“The final report was submitted to the SaTH in December 2017 and it made 37 recommendations to drive improvements. At the request of the Trust, the RCOG held a follow up meeting – a table top exercise – in April 2018 during which feedback was heard about improvements that had been made since the RCOG conducted its review.

“A summary of the April 2018 meeting, in which the RCOG stated that there was still work in progress to ensure maternity services were meeting the needs of women and babies, was shared with the Trust who published it as an addendum to the full 2017 report. The initial report and the addendum were published together by the Trust in July 2018.

“The RCOG regrets that the Trust did not accept its initial report and waited six months to publish it alongside the addendum. The RCOG has subsequently performed a review of our invited reviews service and have made improvements including reporting directly to the CQC at the same time that we submit a review to a Trust. We will continue to review the process to ensure that the service remains accurate and responsive to the needs of maternity services as any learning organisation should.

“The RCOG remains fully committed to making improvements in maternity care and we will continue to work with the Ockenden Review and other key partners to ensure the highest standards in maternity care for women and babies.”


Notes to editors:

For media enquiries, please contact the RCOG press office on +44 (0)20 7045 6773 or email

  • The reports are available on the Shrewsbury and Telford Hospital NHS Trust website.
  • The RCOG is a medical charity that champions the provision of high quality women’s healthcare. The primary aim of its invited review service is to help healthcare organisations drive improvements for babies and mothers. For more information about the invited review services, please visit the website.  
  • The RCOG follows the Academy of Royal Medical College’s framework of operating principles for managing invited reviews within healthcare.