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The report addresses how maternity care failed to investigate, learn, and improve, impacting the safeguarding of mothers and babies. It carries forward Local Actions for Learning and Immediate and Essential Actions from the first report, and adds urgent new themes for maternity services across England, noting workforce expansion and ongoing pressures during the Covid-19 pandemic.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/ockenden-report-final-findings-conclusions-and-essential-actions/380587/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/ockenden-report-final-findings-conclusions-and-essential-actions/380587.png","ImageObject",442,249,{"name":88,"@type":89},"PakDamar76","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-24",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does the final Ockenden report focus on?","Question",{"text":108,"@type":109},"It presents findings, conclusions, and essential actions from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, emphasizing failures in investigating, learning, and improving maternity care.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does this final report relate to the earlier report from December 2020?",{"text":113,"@type":109},"It builds on the first report by maintaining the Local Actions for Learning (LAfL) and Immediate and Essential Actions (IEAs), while identifying new themes requiring urgent action across England.",{"name":115,"@type":106,"acceptedAnswer":116},"What time period and number of families does the review cover?",{"text":117,"@type":109},"The review began with 23 families’ cases and expanded to nearly 1,500 families, with experiences occurring predominantly between 2000 and 2019.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},380587,1791252934,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},962090893057,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","OCKENDEN REPORT-FINAL  \nReturn to an Address of the Honourable the House of Commons dated 30 March 2022 for  \nOur Final Report  \nHC 1219  \nOrdered by the House of Commons to be printed on 30 March 2022  \n© Crown copyright 2022  \nThis publication is licensed under the terms of the Open Government Licence v3 .0 except where otherwise stated. To view this licence, visit [nationalarchives.gov.uk/doc/](nationalarchives.gov.uk/doc/)[ ](nationalarchives.gov.uk/doc/)[open-government-licence/version/3.](open-government-licence/version/3.)  \nWhere we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.  \n[This publication is available at www.gov.uk/official-documents](This publication is available at www.gov.uk/official-documents).  \nAny enquiries regarding this publication should be sent to us at [https://contactus.dhsc.gov.uk](https://contactus.dhsc.gov.uk)[ ](https://contactus.dhsc.gov.uk)[ISBN 978-1-5286-3229-4](ISBN 978-1-5286-3229-4)  \n[E02725921 03/22](E02725921 03/22)  \nPrinted on paper containing 75% recycled fibre content minimum  \nPrinted in the UK by HH Associates Ltd. on behalf of the Controller of Her Majesty’s Stationery Office  \nOCKENDEN REPORT – FINAL  \nFINDINGS, CONCLUSIONS AND ESSENTIAL ACTIONS from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust  \nLetter to the Secretary of State for Health and Social Care from Donna Ockenden  \n30 March 2022  \nDear Secretary of State  \nI publish the final report of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, at a time when the NHS continues to face significant challenges arising from the Covid-19 pandemic. In the 2 years of this pandemic since early 2020 the NHS and its staff have had tobe ever more innovative in the ways services are delivered to ensure the provision of high quality care to patients.  \nNHS staff, including maternity teams who have worked throughout this pandemic, are exhausted. We have seen so many frontline NHS staff go above and beyond the call of duty to support and care for their patients in these truly extraordinary times. Our NHS is rightly held in high regard by so many for the lives it savesand the care it provides.  \nHowever, this final report of the Independent Maternity Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust is about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives.  \nThis review owes its origins to Kate Stanton Davies, and her parents Rhiannon Davies and Richard Stanton; and to Pippa Griffiths, and her parents Kayleigh and Colin Griffiths. Kate’s and Pippa’s parents have shown an unrelenting commitment to ensuring their daughters’ short lives make a difference to the safety of maternity care. It was through their efforts that your predecessor, the former Secretary of State for Health Jeremy Hunt requested this independent review. When it commenced this review was of 23 families’ cases, but it grew to include reviews of nearly 1,500 families, whose experiences occurred predominantly between 2000 and 2019.  \nThis final report follows on from our first report which was published in December 2020. In the first report we outlined the Local Actions for Learning,(LAfL) and Immediate and Essential Actions, (IEAs) to be implemented at the Trust and across the wider maternity system in England. This second report builds upon the first report in that all the LAfL and IEAs within that report remain important and must be progressed. For this second report my independent maternity review team have identified a number of new themes which we believe must now be shared across all maternity services in England as a matter of urgency to bring about positive and essential change. Our Local Actions for L","cbCaivAFCRTFigOC","https://ap.wps.com/l/cbCaivAFCRTFigOC","pdf",2969968,250,"English","# Letter to the Secretary of State\n## Publication date and context\n## Failures in investigation, learning, and improvement\n## Origins and family case scope\n## Continuation of Local Actions for Learning and Immediate and Essential Actions\n## Government measures and workforce funding","[{\"question\":\"What does the final Ockenden report focus on?\",\"answer\":\"It presents findings, conclusions, and essential actions from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, emphasizing failures in investigating, learning, and improving maternity care.\"},{\"question\":\"How does this final report relate to the earlier report from December 2020?\",\"answer\":\"It builds on the first report by maintaining the Local Actions for Learning (LAfL) and Immediate and Essential Actions (IEAs), while identifying new themes requiring urgent action across England.\"},{\"question\":\"What time period and number of families does the review cover?\",\"answer\":\"The review began with 23 families’ cases and expanded to nearly 1,500 families, with experiences occurring predominantly between 2000 and 2019.\"}]","OCKENDEN REPORT - FINAL - Findings, Conclusions and Essential Actions | PDF",1790240764,88]