Image source, SATH

The Ockenden report comes with a lot of recommendations, some for the hospital trust in Shropshire and some for the NHS nationally.

The Shrewsbury and Telford Hospital NHS Trust has been handed 60 local actions for learning, in light of care received by 1,486 families.

These cover nine areas, which include improving the complaints procedure, the involvement of families in investigations and the care of vulnerable and high-risk women.

There are also 15 “immediate and essential actions” the report suggests all maternity services across England should take.

They include a “multi-year investment plan” in maternity staffing, more time for staff training and improvements the way investigations are handled when something goes wrong.

Rob Sissons
BBC health correspondent

The two families who really got the ball running with this, they both lost baby girls a few years apart and they started digging.

They trusted their instincts that things had gone catastrophically badly for them and they realised that the trust was lacking in so many areas.

They started digging for more cases. They got 21 together, 23 including those two that campaigned, and went to the then-health secretary Jeremy Hunt and got this investigation going.

Prior to that, there had been investigations but they'd been in-house, the trust investigating itself.

The risk is, were it not for these two families, would we still be looking at a situation where this was still going on?

Michael Buchanan
Social Affairs Correspondent, BBC News

The report features a lot of criticism of the attitude of the Shrewsbury and Telford Hospital Trust towards serious incidents.

Many incidents did not have an investigation and the Ockenden team graded those reviews that were carried out as poor in almost half of stillbirths and over a third of neonatal cases

It also said they lacked compassion and “transparency and honesty”.

The report also found that when mistakes did happen, they were often “inappropriately downgraded” from a serious incident and the Trust used its own review system, outside NHS guidelines, "apparently to avoid external scrutiny.”

While summing up her report, Donna Ockenden spoke about two cases, which until now have gone unreported.

Both happened in the eight months before the death of baby Kate Stanton Davies and Ockenden said she was talking about them now, with the permission of the families.

She said in the case of baby Joshua in 2008, the mistakes made his care and the care of his mother, were almost identical to the ones later made in the case of baby Kate and her mother Rhiannon.

And she said with baby Thomas in 2009 "there were gross failings in the care provided and yet the Trust did not tell the truth to the family".

"Unfortunately these cases were not isolated incidents." She said.

"This was a trust with significant problems," says Donna Ockenden.

And while external reports indicated the maternity service needed to improve, "the trust was of the belief that its maternity services were good".

"They were wrong," she says.

More from Donna Ockenden who has been talking at length following the publication of her report.

She says her team were concerned about the lack of transparency within the trust, and the lack of honesty shown to families.

She also talks about the number of women who died while giving birth.

"We have fully reviewed the cases of 12 mothers who lost their lives giving birth at the trust. 75% of the cases of maternal death have been graded by our team as categories two and three with significant or major concerns in the care provided."

She says a significant number of mothers and babies were given care that fell way below the standards expected and this continued through the whole period of the review between 2000 to 2019.

The boss of the Shrewsbury and Telford Hospital NHS Trust has released a statement in response to the findings of the Ockenden report.

Chief executive Louise Barnett says: "Today's report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust.

"We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.

"Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden report, and we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve."

Donna Ockenden tells the press conference the maternity services at the trust "failed both families across Shropshire, and sometimes their own staff, over a prolonged period of time".

She says "four key pillars" have been identified to drive forward improvements at maternity services at the trust and all other trusts across England - safe staffing levels properly funded, a well-trained workforce, learning from incidents and listening to families.

"Whilst progress has been made in some of these areas, there must now be a fully funded and then concerted effort by all NHS trusts across England to ensure that these four pillars are the foundation, the road map, and the blueprint of all maternity services going forward," she says.

Donna Ockenden goes on to talk about the case of baby Olivia who died shortly after being born in 2002.

Her mum repeatedly tried to raise concerns about the failings at the trust in the hope someone would do something, Ockenden says. Olivia's mum went on TV to talk about the issue - but says she felt like a "lone voice in the wind".

During the time that Olivia's mum was trying to raise concerns, other babies also died.

The trust was investigated by the Healthcare Commission but failed to take the action needed - the "external scrutiny of the trust clearly failed", says Ockenden.

"So many parents told us they tried to raise concerns but they were not listened to."

Donna Ockenden - the chair of the inquiry - turns to some of the figures highlighted in the report.

When reviewing the stillbirths and neonatal deaths between 2011 and 2019, the review found 40% of the stillbirths they reviewed had not been investigated by the trust.

In the same period, 43% of the neonatal deaths had not had a trust investigation.

Without an investigation, we cannot understand what may have gone wrong, learn and improve care, she says.

The mistakes made in maternity care at Shropshire hospitals must not be repeated, the report's author Donna Ockenden says.

“There should never again be a review of this scale, in both numbers and the length of years across which these concerns remained hidden," she writes in the report.

She also said the legacy of this review “should be a maternity service across England that is appropriately funded, well-staffed, trained, motivated and compassionate and willing to learn from failings in care.”

“Going forward, there can be no excuses”, she says.

Donna Ockenden, the chair of the review, is now speaking - and starts by paying tribute to the families involved. She says what happened to them "really matters" and their experiences will ensure safe maternity care for all in the future.

She says the families also want to thank the journalists covering the story - saying their support has been important.

The last two years have been the toughest in memory for the NHS, she says - and teams including maternity units have been stretched. Maternity staff say they are exhausted, she adds.

We are right to be proud of our NHS, she says - but the Shrewsbury and Telford NHS Trust failed families across Shropshire and their own staff across a prolonged period of time.

Image source, EPA

Health Secretary Sajid Javid has released a statement on the report, which he says "paints a tragic and harrowing picture of repeated failures in care over two decades".

"I am deeply sorry to all the families who have suffered so greatly," he adds.

"Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.

"I would like to thank Donna Ockenden and her whole team for their work throughout this long and distressing inquiry, as well as all the families who came forward to tell their stories."

Javid will also make a statement to MPs in the Commons later today.

The trust, NHS England and the government have accepted the report’s recommendations and will now consider the details. The NHS announced last week that £127m will be invested in maternity services in the next year, and a new Special Health Authority specifically to carry out maternity investigations was announced in January 2022.

The Ockenden report highlights ineffective monitoring of babies' growth and a reluctance to perform caesarean sections. It also found:

• The failures at Shropshire’s maternity units were not challenged internally, or by outside bodies that should have been holding them to account
• Hundreds of cases were found where the trust failed to carry out appropriate serious incident investigations
• As a result of all the failure to investigate properly, there were missed opportunities to learn and serious incidents were repeated.
• There was a shortage of staff and a lack of ongoing training
• There was "a culture of not listening to the families involved"

The report into baby deaths and maternity failings at the Shrewsbury and Telford Hospitals NHS Trust has just been published.

While we go through it in detail, here are some of the headline findings:

• There have been "repeated failures in the quality of care and governance” at the Shrewsbury and Telford Hospital Trust over the past two decades, the report says
• At least 201 babies would have survived if they had received better maternity care - made up of 131 still births and 70 neonatal deaths
• In addition, at least 94 children suffered avoidable harm due poor maternity care, including cerebral palsy and hypoxic brain injuries

• A further nine mothers died due to major or significant concerns about their care

The chair of today's report has been tweeting, external her thanks to everyone involved in its creation.

Donna Ockenden says more than 90 clinicians had been involved in the project.

She also says she wanted to thank her own "wonderful team of midwives and every kind of doctor involved in the delivery of safe maternity care".

We are expecting the full report to be relased in the next few minutes so stay with us for live updates and reaction.

Image source, PA Media

The Deputy Prime Minister, Dominic Raab, has said the wait for today's report has been long and "agonising".

But he adds: "Ultimately I think what people want is answers and the confidence to know that the problems, systematic as they were, have been addressed."

Raab also says it has been "difficult" to get answers in this investigation and to "unturn all the stones".

Politicians are speaking to the BBC ahead of the publication of the Ockenden report into baby deaths and maternity failings at the Shrewsbury and Telford Hospitals NHS Trust.

Labour's Shadow Health Secretary Wes Streeting has highlighted a shortage of maternity staff.

"The thing that really concerns me is that one of the key factors in providing a safe service is safe staffing levels and there is a shortage of staff across the NHS."

He adds: "It’s particularly acute in maternity services, where midwives are leaving faster than we’re able to recruit them."

A couple who campaigned for this report say it "gifted the NHS the opportunity to learn".

Richard Stanton and Rhiannon Davies's daughter Kate died hours after her birth in March 2009.

Mrs Davies says: "This report can be a difference, this report could be a legacy, it should be."

The trust at the centre of the largest ever review of maternity care in the NHS has previously apologised for failings and we are expecting to hear its response after the report is released later.

Here's part of a statement the trust made following the BBC's Panorama programme Maternity scandal: Fighting for the truth and you can read it in full here., external