AvMA reaction to the Ockenden Report

Published: 31 Mar 2022

AvMA warmly welcomes the Ockenden Report of the Shrewsbury and Telford Maternity Scandal published on 30th March 2022 and pays tribute to the women and families whose bravery and tenacity have made this possible. However, like many others, AvMA is frustrated that the lessons from inquiries like this so often are lost after the initial shock and the recommendations are often never implemented.

Some of the recommendations from the Morecambe Bay inquiry and the Mid Staffordshire public inquiry have still not been implemented. Even some of the interim recommendations published by Donna Ockenden last year, prior to publication of the final report because of their urgency, are yet to be taken forward.

In particular, there has been little or no progress on the recommendation to create the role of ‘Senior Independent Advocates’ to support and advise women who have problems with maternity services. Many women and families at Shrewsbury and Telford and at Morecambe Bay (as well as East Kent where another maternity scandal has resulted in an inquiry to be published later this year) would have benefitted from such an independent service.

It has even been suggested that the independent advocacy service, which has yet to be defined, might be provided by NHS England itself. In AvMA’s experience, women and families in these circumstances would not see NHS England as ‘independent’ and could not have confidence in such a service run by the NHS itself.

AvMA also wants the people responsible for scandals like this to be held to account and not to be able to take up similar roles elsewhere, through the introduction of regulation of senior NHS managers similar to that for doctors and nurses.

Peter Walsh, chief executive of AvMA, said:

“The recommendations from the Ockenden Inquiry, including the interim recommendations, must be implemented in full and rapidly. In particular, the calls for extra resources, echoed by the Health and Social Care Committee, must be met. There should be a formal committee established with the specific remit to monitor the implementation of recommendations from inquiries which have been accepted and call Government and the NHS to account if they are not being implemented properly.

“There must also be accountability for senior managers responsible for awful scandals like this. There should be regulation of senior managers similar to arrangements in place for doctors and nurses, so that they can be struck off a register and prevented from taking on similar roles.

“Women and families who experience problems with maternity services must be listened to and empowered both before harm is caused to mother or baby or after harm has been caused. It is heart-breaking that women and families are left to fend for themselves.

“Donna Ockenden’s recommendation of independent advocates has the potential to help massively in this regard, but such a service can only have the confidence of women and families if those advocates are truly independent of the NHS and part of organisations with a track record in providing specialist advice and advocacy.”