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06 Sept 2025

Ockenden report raises 15 areas for ‘immediate action’ in England maternity care

Ockenden report raises 15 areas for ‘immediate action’ in England maternity care

The Ockenden report has raised 15 areas for “immediate and essential action” to improve care and safety in maternity services across England.

Areas such as safe staffing, escalation and accountability, clinical governance and robust support for families have all been included as “must dos” by maternity expert Donna Ockenden in the 234-page document.

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

The report said maternity and neonatal services in England require a multi-year settlement from NHS England “to ensure the workforce is enable to deliver consistently safe” care.

It also says staffing levels across maternity services should be escalated to senior management when the agreed levels are not achieved.

Staff being able to escalate concerns and incident investigations being meaningful for families have both been described as essential action that needs to be taken across the country.

The report says staff who work together must train together, and should attend regular mandatory training.

It also states women who choose birth outside of hospital should receive accurate advice.

Appropriate bereavement care services should be put in place for mothers who suffer loss during pregnancy and clear pathways of care should be in place for provision of neonatal care, the report says.

The mental health and wellbeing of mothers also forms part of the essential action, with partners and families as “integral” to all aspects of maternity service provision.

The document indicates every trust should have a “patient safety specialist” dedicated to maternity services, and that all leaders are trained in human factors such as family engagement.

Language in investigation reports should also be easy to understand for families, the report says.

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