Donna Ockenden says her report highlights themes that must be shared across all maternity services in England as a 'matter of urgency to bring about essential change' to improve safety. 📺 Sky 501, Virgin 602, Freeview 233 and YouTube
The independent review chaired by midwife Donna Ockenden examined 1,592 clinical incidents involving 1,486 families. Most of the incidents occurred between 2000 and 2019.
Chair of the review Donna Ockenden said:"Throughout our final report we have highlighted how failures in care were repeated from one incident to the next. "The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved. There was a tendency of the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths.
"Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require."The review has also outlined 15 areas in which all maternity services in England must take action to improve patient safety.
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