Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust

Donna Ockenden · work from 2017 · published 2022

What this was

Independent review of maternity services at Shrewsbury and Telford. An interim report in 2020 set immediate actions. The final report in March 2022 set 15 immediate and essential actions for maternity services in England, after reviewing failures across maternity and neonatal care.

Why it sits in the hub

The essential actions became the national maternity safety checklist. East Kent, published the same year, warned that another checklist would not be enough. Nottingham in 2026 found many of the same failures still in place.

Findings

Finding 1
Women were not listened to, babies were harmed, and investigations did not produce learning.
Learning from harm Listening to patients and families Maternity and neonatal care
Finding 2
Staffing, training and escalation were not reliable enough for the acuity of the service.
Maternity and neonatal care Safe staffing Training and competence

Recommendations in this hub

The source reports 15 recommendations or essential actions. The notes below are a paraphrase, not the official text.

1Partly doneMaternity services
Listen to women and families, and give them a route to senior review when they are worried.
Listening to patients and families Maternity and neonatal care
2Partly doneNHS England and trusts
Fund a workforce plan that matches the complexity of the women being cared for.
Maternity and neonatal care Safe staffing
3Partly doneTrusts
Protect multidisciplinary training and a supernumerary labour-ward coordinator.
Safe staffing Training and competence
4Partly doneTrusts and ICBs
Investigate incidents properly and share the learning across the local system.
Learning from harm