Response to Ockenden Report

Our response to the Ockenden report: 22 February 2022

In December 2020, the Ockenden Report was published, which set out immediate and essential actions for maternity services across England under seven key themes. The Ockenden report was written following a review at another NHS Trust in response to a letter from bereaved families, raising concerns where babies and mothers died or potentially suffered significant harm while receiving maternity care at the hospital. Recommendations were issued for all acute Trusts offering maternity care and the wider maternity community across England to be addressed as soon as possible.

Key actions that we have taken in response to the Ockenden report are summarised below:


1. Enhanced safety

We have robust processes to ensure that any serious incidents are reported to our Board and to our commissioners, while meeting the requirements for external input and oversight. We also report performance against a range of safety measures to the Trust Board on a regular basis in addition to the Healthcare Safety Investigation Branch for external oversight.


2. Listening to women and their families

We work closely with the local Maternity Voices Partnerships (MVPs) to ensure that voices of maternity service users, local women and birthing people are heard, and they have a real say in how our maternity services are provided.

Spencer Prosser, Chief Financial Officer, has taken up the role of executive safety champion on the Trust Board, while Steve James has taken up the role of non-executive director lead for maternity.


3. Staff training and working together

We have provided enhanced staff training to meet the recommendations of the Ockenden report. We have also increased funding for staff posts, creating additional midwifery posts and consultant obstetrician posts. We are working hard to fill vacancies. We are meeting the requirement to carry out consultant-led labour ward rounds twice a day (over 24 hours) and seven days per week.


4. Managing complex pregnancy

We are working closely with our partners across south east London to improve the care of women and birthing people who have complex medical needs, by  establishing a maternal medicine network.


5. Risk assessment throughout pregnancy

We have carried out audits to provide assurance that risk assessments are completed and recorded for everyone who uses our services. This includes ongoing review and discussion of intended place of birth.


6. Monitoring fetal wellbeing

For many years, we’ve had a fetal wellbeing team, including consultants, obstetricians, and senior midwives to ensure that maternity staff are trained and competency assessed in this area.


7. Informed consent

We are carrying out a review to ensure that we provide clear and accessible information to users on every aspect of their care with the Trust.