When in late 2017 the senior midwife Donna Ockenden read the case files of the 23 families who had demanded a review of maternity services at Shrewsbury and Telford Hospital NHS Trust, she came to a grim realisation: these accounts were so shocking that there must be more. The review was expanded to almost 1,500 families. It looked at 12 maternal deaths and concluded that not one woman had received care in line with best practice, and at 498 stillbirths, where it found “significant or major concerns” about care in a quarter of cases. The report, published in 2022, found the maternity service had “failed to investigate, failed to learn and failed to improve”. Ockenden said the culture became so toxic some mothers were blamed “for their poor outcomes, in some cases even for their own death”.
Two weeks later Ockenden, now 56, received a letter from families in Nottingham who had campaigned for a review of Nottingham University Hospitals NHS Trust, where dozens of babies had suffered serious injuries or died between 2010 and 2020. Again, she had what she now calls a “Shrewsbury moment”: the terrible understanding that “there must be more”. She and her team are now reviewing the accounts of more than 1,800 families in what will likely be the largest ever review of a single NHS service. “I was so saddened, but not surprised that the numbers have escalated in this way,” Ockenden told me when we spoke on a video call.
The work often weighs heavily on her. “There are accounts of some families that will stay with me for the rest of my days,” she said. Ockenden picks her words carefully: she refers to “family accounts” not “stories”, for instance, because she says the latter brings to mind fairy stories – something made up. She concluded the 2022 Ockenden Report not with a list of “recommendations” – she had seen too many of those such reports “sat on a shelf gathering dust” – but with 84 “immediate and essential actions”. The then health secretary Sajid Javid accepted all of them, although, she notes, he called them “recommendations”.
Among her actions/recommendations was increasing maternity funding by £350m a year; the government has committed less than half that. In 2022-23, 41 per cent of clinical negligence payments made by NHS England were for maternity and neonatal services. The Quality Care Commission now considers nearly two-thirds of England’s maternity units substandard. Ockenden argued that many problems in the maternity service are linked to more than a decade and a half of underfunding (she also stressed that her role requires her to remain politically neutral and she would not be drawn into a political discussion, or comment on cases such as that of Lucy Letby). The Royal College of Midwifery has warned of a national shortage of 2,500 midwives. Is chronic under-resourcing a reflection of sexism – maternity services are, after all, mostly run by women, for women? Ockenden thought for a moment. She had no evidence, she said, that it was.
One of the many shocking findings in the Ockenden Report was that, alongside medical failings, there had been a breakdown of compassion, with women describing the midwives and doctors as “uncaring”, “horrible” and “bad tempered”. “I felt like I was on a butcher’s slab,” said one. What causes this lack of kindness? While pressure plays a role, Ockenden replied, “There are cultures that develop, a them-and-us culture, between the workforce and the families… That culture is perpetuated on a daily basis, a bit like a snowball rolling down a mountainside. It just gets bigger and more impenetrable as time goes on.”
Another problem at Shrewsbury was “this was a culture of achieving vaginal births at all costs”, Ockenden said. The trust’s caesarean rates were considerably lower than the national average and, in many instances, the outcome for the mother and baby would have been much better had a C-section been attempted earlier. “My doctors, who have got hundreds of years of experience [between them], threw their hands up and said: ‘I can’t believe I’ve just read that.’” What matters ultimately, she said, is that women are able to make informed choices about how they give birth and that they are listened to.
Ockenden – who was warm, no-nonsense, and smartly dressed in a polka-dot shirt, with bold lipstick and dark-framed glasses – is the eldest of five children and spent her early years in Wales. Her father worked on building sites six days a week; she recalls him going to work in wet trousers because his only pair never dried overnight. In 1973 he moved to Abu Dhabi for work and a few years later his family joined him. But then Ockenden’s parents’ marriage ended and she returned to Britain with her mother. “It’s fair to say that our life after that was chaos,” she said. She wants to say only that her mother was “troubled”. By the time she was 18, Ockenden and her family were homeless, staying in a hotel in Bristol, and she was left in charge of her siblings.
“I remember asking all sorts of people for help, and that included some family members, and no one would help me. I [had] some very bad days… You can’t have an experience like that and come out unchanged.” When we spoke, she had recently visited a hospital in Bradford where, in response to high rates of poverty, mothers can ask at their antenatal appointments for a “Betty bag”, a discreet white bag containing food. Seeing the Betty bags, neatly lined up, she had struggled not to cry. “I remember being in that position where I had to think how I was going to feed my siblings, and you don’t forget,” she said. She promised herself that if she was ever in a position to help others, she would. In 2016 she and her two daughters began bringing out food to homeless people in their hometown of Chichester. By 2017, they had set up a charity, the Four Streets Project, that hosts a nightly takeaway “supper club” in a church.
Ockenden began her nurse training in 1986, commuting between Wales and Bristol, where her mother and siblings were still living. She remembers observing her first birth: “It’s a very embarrassing story.” She was so eager to phone her mother to tell her she’d seen a baby being born that she left the room too early, before the afterbirth had been delivered, and received a telling off from the midwife, “very rightly”. After that, she knew she wanted to become a midwife. By 2013 she was a clinical director for the London Maternity Strategic Clinical Network, and began taking on smaller NHS reviews, initially of elder care services in Wales.
Over 30 years she has witnessed changes to midwifery: antenatal appointments are now just 20 minutes, midwives have less “time to care”, and the paring back of postnatal services means that they are no longer able to play the role they once did supporting new families. Meanwhile, many families also have more needs because of higher rates of poverty, deprivation and physical ill health. “Maternity is not an island, some little paradise that is completely separate from what is going on in our cities and towns,” she said.
Donna Ockenden does not expect her review of Nottingham maternity services to conclude until at least September 2025, but in the meantime she is meeting with the trust every two months to share early findings. Recently, for example, she flagged the need for more translation services for the city’s diverse, multilingual community. Families should never have had to call for an independent review, but at least they now have one. “I think we’re at a stage when families speak out, they are listened to,” she said. “Although the scrutiny and the attention on the maternity services can be very difficult and painful, it does mean that those people from the very top of government down fully understand what needs to happen. That does give me hope.”
[See also: The maternity unit is no place for a culture war]
This article appears in the 25 Oct 2023 issue of the New Statesman, Fog of War