13 October 2022

Dr Catriona McMahon, Chair of The Shrewsbury and Telford Hospital NHS Trust, said

“I would like to apologise again to Ms. Davies and Mr. Stanton for their loss and the way in which the Trust dealt with their concerns. We also wish to extend our apologies to other families who have been more widely impacted by the findings of this report. 

“Our aim in commissioning this independent report was to investigate, transparently, the complaints made against the former chair and we have committed to follow-through with actions to address the issues it highlights. 

“Local mothers and families tell us services are improving but we know there is still much more to do, and we will continue to work with our local and national partners to deliver safer and more effective care.” 


Background Information on the Scolding Report

The Board of Directors has accepted the findings of Fiona Scolding KC’s independent report into complaints made against a former Trust Chair. The Board is already committed to a Board Governance Review to address all relevant findings and criticisms from the report. This is in addition to work already undertaken.

Ockenden Report action progress

  • 45 (87%) of the fifty-two actions set out in the first Ockenden Report have been delivered, this means that SaTH has delivered on all but one of the actions it is the lead for. The Trust is collaborating closely with partners to achieve the remaining actions.
  • The final Ockenden Report provided a further 158 actions for SaTH to deliver.  58/158 actions (37%) are now delivered, with 44 of these (28%) evidenced, and assured.  59/158 actions (37%) are on track to deliver by their planned date, and we are in the planning process for the remaining actions.



  • The Trust has invested in a further eight consultant obstetricians, which now enables on-site consultant obstetrician cover 24/7, based on the Delivery Suite. We remain one of only a few Trusts in the country to have this level of staffing.
  • Other changes have been made within the senior team, including a new Director of Midwifery, a new Divisional Director of Operations and two new Deputy Directors of Midwifery.
  • Investments have been made in the Clinical Governance support team, and two new specialist fetal monitoring lead midwives have been appointed alongside a lead consultant to focus and champion best practice in fetal monitoring.
  • 100% of the Trust’s 2021 cohort of registered midwifery preceptees – progressing from Band 5 – Band 6, have remained with the organisation.


Regulator feedback

  • The 2021 inspection of our hospitals by the health regulator, the Care Quality Commission (CQC), highlighted “outstanding practice” in our Maternity Services and set out how maternity staff “showed immense levels of resilience as they were able to continue to provide high levels of care to women and babies and maintained a positive and caring attitude during extremely challenging circumstances.”
  • The latest CQC Maternity Patient survey – which is based on direct feedback from those we care for – showed SaTH was one of only seven trusts, out of the 122 in the survey, which was performing at a “better than expected” level.
  • NHS England recently assessed how well we have delivered the Immediate and Essential Actions from the first Ockenden Report (They are doing this for all maternity providers), using a panel of experts from outside the Trust. These are called the Insights assessments.  They gave us a rating of 89% compliance and many positive comments.  The actions we haven’t yet delivered are primarily dependent on external organisations to deliver.


Governance and Assurance

  • SaTH is working hard to ensure that positive achievements are sustained and can be evidenced, and has revised the governance and assurance systems and processes in maternity services to ensure these are robust. This includes making progress on improving transparency and accountability at all levels of the organisation.
  • SaTH has a reciprocal arrangement with Walsall Healthcare NHS Trust whereby each Trust reviews both their own and each other’s cases of stillbirth, using the validated Perinatal Mortality Review Tool and process, to provide extra scrutiny.
  • Monthly live-screened meetings of our independently-chaired Ockenden Report Assurance Committee with external stakeholder membership including MVP, NHSE/I, ICS, Healthwatch Shropshire and CHC Powys so anyone can hear for themselves what we are doing and ask questions.
  • SaTH has a well-publicised Freedom to Speak Up offering with three Guardians and a network of Advocates to create a culture of openness and transparency where speaking up and raising concerns are everyday business and ensuring that there are no repercussions for those that raise concerns.
  • A broad range of Staff Health and Wellbeing support is available to colleagues, including The Shropshire and Telford & Wrekin Staff Psychological Wellbeing Hub which is staffed by qualified mental health professionals.
  • ImproveWell has been introduced in Maternity Services. ImproveWell is a digital engagement platform that enables colleagues on the ‘shop-floor’ to share their feedback and improvement ideas. The app provides a conduit for staff voices to be heard and for meaningful change.


Improvements in Care

  • Improved management of birth options for women and associated risk management, including the introduction of birth option clinics and review of birthing plans/preferences at every contact and a named consultant for ‘high risk’ pregnancies.
  • The Baby Buddy app launched in 2019 and Badgernet, is an online portal and app that allows service users access to their maternity records, was rolled out in 2021 to provide support and information and to give women greater control over their pregnancy record and care notes.
  • We focus on listening to women and families and we have a close relationship with our Maternity Voices Partnership (MVP), co-working on initiatives including the User Experience (UX) system which captures positives and areas for improvement from our current and former service users.
  • Birth Preferences Card and a visual birth preferences card have been co-produced to enable service users to discuss and amend their preferences with their care team throughout pregnancy and into labour.


Available Support

For anyone to access:

As always, local and national support systems are available for anyone to access, as follows:

  • NHS 111 can be called using 111 if it is out of hours and you do not think it is an emergency situation. They will also link you to local services if you cannot find a local GP or hospital.
  • Samaritans 08457 90 90 90 – The Samaritans are there to talk to 24/7 and will offer help in tough times.
  • Mind 0300 123 3393 – Mind is a mental health charity that provides support. There is a link at the top of their webpage titled “I need urgent help” which will ask a number of questions and provide you with advice in your situation.
  • Call 999 – For medical and mental health emergencies

For current and former staff:

The Staff Wellbeing Hub, available to current or former members of staff:

If a current or former staff member wishes to talk to a psychologist with concerns around maternity and/or the Ockenden Review, then please use the following:

  • Phone the Hub between 9am-5pm, or email or use the online referral out of hours
  • You will be given an appointment with one of our psychologists (working in Midlands Partnership Foundation Trust (MPFT) and given their name).  These are all evening appointments and will be via phone or Microsoft Teams