RCM response to Ockenden review into maternity services at Shrewsbury and Telford

By RCM on 30 March 2022 RCM Women Wellbeing Of Women Midwifery Maternity Safety Multi-disciplinary care

Poor culture and leadership must be addressed if we are to make our maternity services the safest place to give birth. This statement from the Royal College of Midwives (RCM) came as the final report of the largest ever review of NHS maternity services was published. The RCM acknowledged that the pain and suffering of the families had been worsened by having to fight for answers and vowed to work with NHS bodies and other professional organisations to ensure lessons are learned from these tragic failings.

Today the RCM has pledged to continue its work to be part of the solution to

safety improvements and support its members to do the same not only at Shrewsbury and Telford NHS Trust, but throughout all maternity services across the UK.

Commenting, the Royal College of Midwives’ (RCM) Chief Executive, Gill Walton said

“It is heartbreaking that this report only came about because of the determination of the families. We owe them a debt that I fear can never be repaid. What we can do - all of us who are involved in maternity services – is work together to ensure we listen, and we learn from this and ensure that women and families have trust in their care.

“This review must be a turning point for all those working in maternity services. The actions recommended are measured and sensible and reflect much of what the RCM has been calling for. We hope that those in a position to enact them – NHS England and the Department for Health & Social Care – will do so in partnership with organisations like ours and with haste.”

A poor working culture, where staff were afraid to raise concerns, has been cited by the report as a key factor in many of the cases. Earlier this year the RCM called for a seismic NHS cultural shift to improve maternity safety as it published guidance for its members to raise concerns about maternity care which outlined steps staff can take and what to do if they feel they are not being listened to or their concerns are ignored.

Gill added:

“We all have a responsibility to speak up and speak out about poor behaviours and poor care in our workplaces. I am asking midwives, maternity support workers, obstetricians and anyone working in maternity services to look around them and ask themselves is the care being provided where you work safe? If it’s not, I need you to have the courage to speak up, raise your voice and stand up for higher standards. Poor working cultures lead to a lack of timely and appropriate escalation, which in turn compromises safety.  This has to stop.”

The review has identified workforce shortages as being a threat to safety. The RCM has been highlighting this for over a decade, calling on three successive Health Secretaries to invest not only in recruitment but retention of midwives. Evidence shows that midwives are essential to the delivery of safe women centered care for far too long underinvestment in staffing has undermined midwives’ efforts to deliver the safest and best care for women and their babies.

On workforce, Gill said: “It is not good enough that the Government only pays attention to maternity services in the light of a tragedy such as happened at Shrewsbury and Telford. If they truly value maternity services – those who access them and those who work in them – they have to ensure not only that there are enough midwives, but that they have the right mix of skills, training and experience to deliver care in the right place at the right time. We welcome the report’s focus on improving staff retention and its recommendation that every newly qualified midwife should have a robust induction training programme.

“We also endorse and support its recommendation to ring fence training budgets and ensure that those midwives who go on training courses are replaced. All too often our members tell us that crucial training has been put on hold due to no-one being able to backfill their posts.

“We also welcome the endorsement of the RCM’s long-held view that improving midwifery leadership is a key factor in improving safety in maternity services, but that midwifery leaders need the right level of influence, resources, staffing to be effective. If we can get staffing levels right and invest in leadership and more multi-disciplinary training, we can begin to turn things around.”


To contact the RCM Media Office call 020 7312 3456, or email [email protected]. 

Notes to Editors: 

The review team have also reported that there was a clear determination by the Trust to keep caesarean section numbers low which led to severe and significant failings in the care of mothers and babies. The RCM say it has already apologised if any advice we have given to our members as part of the Campaign for Normal Birth, which was suspended in 2014 led to delays to care which may have caused harm.

The Royal College of Midwives (RCM) is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team.  We provide workplace advice and support, professional and clinical guidance, and information, and learning opportunities with our broad range of events, conferences, and online resources. For more information visit the RCM | A professional organisation and trade union dedicated to serving the whole midwifery team