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Dark day for maternity services as RCOG responds to the final Ockenden review

30 Mar 2022

The Royal College of Obstetricians and Gynaecologists (RCOG) responds to the findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust.

The report found a lack of staffing, adequate training, effective investigations and governance at the Trust, as well as culture of not listening to families, led to failures in care and many incidents of babies dying during or shortly after birth and babies and women suffering lifelong conditions as a result of their care and treatment.

Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said:
“We welcome the findings and recommendations of the independent review, and are committed to continuing our work to ensure that every woman and their baby has the best possible care and maternity experience, whilst reflecting on the uncomfortable truths contained in this report.

“Above all, our sympathies go out to all of the families who have experienced tragic maternity outcomes. Each maternal death, and the death or injury to a baby is devastating, and we owe it to all those affected by these tragedies to act swiftly on the recommendations to ensure these are not repeated.

“The review team have investigated a significant number of cases and listened intently to the voices of families and staff. We are enormously grateful to the review team for the support shown to the families affected and enabling them to play such an important role in driving the vital and far reaching change that is so urgently required.

“We have made important progress since the interim review and it was positive to see the RCOG’s recent guidance on locum usage and the roles and responsibilities of a consultant included within the recommendations of the report. Our focus must now be on translating learning into practice, and joining up current programmes and resources within the maternity system to promote personalised care.

“The report contains an extensive number of local actions for learning for the Trust which must be taken forward with decisive action and kind and compassionate leadership. It also includes immediate and essential actions for all maternity services. Together with the Royal College of Midwives and other medical organisations and charities dedicated to the safety of pregnant women and their babies, the RCOG will look in detail at the report's findings and its recommendations and will embrace together the changes necessary to implement them.

“We welcome the recommendation to establish a College-led advisory group to support the Maternity Transformation Programme and look forward to shaping it. This investigation has been a watershed moment for maternity services, and growing on our response to the interim findings, we will continue to work on improvements which have an impactful change on maternity services.

“The RCOG is committed to enacting change, and a clear focus of this change must be to build and maintain safe staffing levels and positive workplace cultures. Protected time of staff training is vital, and this is only possible if there are enough staff. While we welcome the recent Government funding for maternity services, we also hope to see £200-250m additional funding to ensure safe staffing in midwifery and obstetrics as recommended in this review and the Health and Social Care select committee report in 2021.

“We recognise that many doctors and midwives reading this report today will feel demoralised and as leaders of the profession, we are committed to supporting our members and allied health professionals to deliver the best care. This needs real and total commitment from our government and the NHS at every level to provide adequate staffing, training and the ability to learn from every incident to enable doctors and midwives help every women and family have a safe birth.”


Notes to editors

For media enquiries please contact the RCOG press office on +44 (0)7740 175342 or email

RCOG maternity safety projects:

  1. Each Baby Counts (2015-2018) was the RCOG’s national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents during term labour.
  2. Each Baby Counts + Learn & Support is a joint initiative between the RCOG and RCM to help improve maternity care in England, looking at issues around workplace culture and staff wellbeing. 
  3. The Avoiding Brain Injury in Childbirth Collaboration (ABC) project with the RCM and The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, aims to develop a new nationally agreed approach for monitoring and response to fetal wellbeing during labour.
  4. The RCOG and RCM’s Tommy’s National Centre for Maternity Improvement is piloting a new digital tool to identify and support women with higher risk pregnancies. This tool will produce a more accurate and personalised assessment of a woman’s chance of developing pregnancy complications that can lead to adverse outcomes, including stillbirth and preterm birth.
  5. The National Maternity and Perinatal Audit (NMPA) Rapid Quarterly Reporting presents timely data on care practices and maternity outcomes in NHS hospitals in England. It is designed to support service improvement; to provide information to women and families on results in their local NHS hospital; and to allow evaluation of national trends.
  6. The RCOG’s new workforce planning tool which will launch this summer aims to improve how maternity units calculate their medical staffing requirements, to better support families and babies.
  • Policy and governance
  • Pregnancy and birth