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Donna Ockenden is a senior registered midwife who was asked to undertake an independent review into the maternity services at Shrewsbury and Telford Hospital NHS Trust. The purpose of the review  was to independently assess the quality of investigations relating to newborn, infant and maternal harm at the trust.

The final Ockenden report has been published and you can read it here.

Within the report are seven immediate and essential actions that need to be taken by all maternity providers to improve safety in maternity services. The Local Maternity and Neonatal System (LMNS) seeks assurance from providers on their work to meet the Ockenden actions.

Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks. Neighbouring Trusts must work collaboratively to ensure that local investigations into Serious Incidents (SIs) have regional and Local Maternity System (LMS) oversight.

Maternity services must ensure that women and their families are listened to with their voices heard.

Staff who work together, must train together.

There must be robust pathways in place for managing women with complex pregnancies. Through the development of links with the tertiary level Maternal Medicine Centre there must be agreement reached on the criteria for those cases to be discussed and /or referred to a maternal medicine specialist centre.

Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway.

All maternity services must appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion best practice in fetal monitoring.

All Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.

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