The 2020 Ockenden Report: our response
In December 2020, the Ockenden Report was published, which set out seven immediate and essential actions for Trust maternity services under 7 key themes.
The Ockenden report was written in 2020 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 whilst 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.
There are seven immediate and essential actions (IEAs) within the Ockenden report and we have worked to summarise our response into a short animation.
| Action | 2020 response | 2026 update | |
|---|---|---|---|
| Action 1 | Enhanced safety: Maternity services must ensure that serious incidents are investigated thoroughly, with input from clinicians and services in their region. | We already have robust processes to investigate all incidents and where indicated we have independent external input and oversight We are working with colleagues in our region to ensure we learn from each other and make services as safe as possible | Governance is“clinically led and data fed”, improving transparency and oversight. We have implemented the Patient Safety Incident Response Framework (PSIRF) to learn from incidents and improve care. We have increased the size of the perinatal quality and safety team and provided training to ensure robust, patient-centred investigations. We have a focus on sharing learning from maternity incidents with teams and safety champions engage with staff to identify and escalate issues. |
| Action 2 | Listening to women and families: Maternity Services must listen to the voices of women and families | We will continue to work closely with the Maternity Voices Partnership to ensure we act on feedback from everyone who uses our maternity services | We have a close working relationship with the MNVP and they regularly attend meetings including our monthly Patient Experience Group where reviews, feedback, concerns and compliments are discussed. |
| Action 3 | Staff training and working together: Staff who work together must train together | We are working to further develop the way that maternity staff from different professions train together and jointly discuss people’s care during the ward rounds, which will be held twice a day | We have a dedicated Practice Development Team who facilitate regular training and education (study days, ward teaching, updates) in areas including fetal monitoring. Our maternity training is benchmarked against the national core competency framework. We run skills drills in our community and acute hospital settings, these are evaluated and fed back into our governance structure We have improved our multidisciplinary governance and communication arrangements. We have daily maternity flow meetings to coordinate care safely. |
| Action 4 | Managing Complex Pregnancy: There must be a clear pathway of care for people with complex pregnancies | Anyone with a complex pregnancy has a named doctor who oversees their care. A plan for your care will be agreed with you. | We use NICE guidance for antenatal care with referral for consultant led care for women with medical co-morbidities and/ or women with complex social factors. Each woman with a complex pregnancy has a named consultant and a detailed plan of care for the pregnancy, discussed and agreed with the woman at their initial consultant antenatal appointment which is documented in their BadgerNotes. This plan is amended throughout the pregnancy in response to developments in the pregnancy and in discussion with the woman. |
| Action 5 | Risk Assessment throughout pregnancy: Staff must ensure that risk is assessed throughout pregnancy | We will undertake a formal risk assessment with you when you book into our services; when you reach 36 weeks; when you go into labour. At every contact, we will talk to you about whether your chance of experiencing any problems has changed and how we can make sure that you have the best possible birth experience. | A risk assessment must be completed for every admission using the BadgerNet digital maternity notes system. We also conduct continuous risk assessment for blood clots during pregnancy and postnatal period and use monitoring tools like MEOWS to detect deterioration. |
| Action 6 | Monitoring your baby during pregnancy: There must be a senior lead midwife and doctor who focus on how babies are monitored during each pregnancy | We use best practice to monitor your baby’s heartbeat during your pregnancy. We ensure that our staff follow national guidelines. | We follow national NICE guidance for fetal monitoring and have a dedicated fetal wellbeing lead midwife who has undergone additional specialist training and is also part of the national fetal monitoring network. The fetal wellbeing lead midwife regularly reviews, trains and audits our monitoring practices. Our fetal monitoring day is planned in accordance with the national core competency framework, is inclusive of a MCQ with a 85% pass rate (SBL v2.3). We have monthly fetal monitoring audits (CEFM and IA), which assess risk assessment, safety standards and escalation. These are evaluated and fed back into our governance structure. |
| Action 7 | Informed consent: Services must ensure that people have the information they need to make choices about where and how to have their baby | We want you to be involved in decisions about your care during your pregnancy, labour and birth. We are working hard to ensure you have all the information you need, so we can support you to make decisions about your care. This includes: Improved Information via Maternity Voices and Gloucestershire Hospitals websites. Launch of The Journey to Parenthood, which is held in your notes for parents and health professionals to review together at every contact through to labour and birth. Digital maternity booking now directs you to antenatal screening choices. | Digital access via the BadgerNotes system has improved access to information and engagement and allows users to view notes, results, messages. We provide birth preparation resources and courses including: weekly online antenatal classes about labour, birth and your choices; access to antenatal information that can be accessed any time and in different languages through the Real Birth Company Campaigns in partnership with the ICB about important topics such as reduced fetal movements; accessible videos with important information all women and families can access through BadgerNet, YouTube and social media. |