he Ockenden report looking at failures in maternity care at Shrewsbury and Telford hospitals (SaTH) published this week makes for truly harrowing reading. The report looks at the first 250 cases of potentially avoidable harm to mothers and babies reviewed as part of a wider investigation of maternity services at the trust going back two decades and beyond. As the father of a baby boy who died avoidably due to serious failures in his care at the Morecambe Bay trust in 2008, the report paints a grim picture of systemic issues that are sadly only too familiar. Without doubt, the most difficult part of the report is reading the stories of personal suffering caused by clinical and cultural failings. These include a woman admitted in labour who, despite requests for a caesarean section, was persuaded to attempt a vaginal birth. A number of complications led to the baby’s death a few days later as the result of a lack of oxygen to the brain during birth. In another example, staff had not explained to a woman the risks of birth in a midwifery-led unit, or provided information about the need for a transfer if complications arose. During her labour, she suffered a catastrophic haemorrhage requiring transfer to a consultant unit, where she died. It’s impossible to overstate the devastating impact of these tragedies on the families affected. They experienced a life-changing trauma, which would only be compounded by a continuing struggle to discover the truth. In light of the report’s findings they now know that opportunities to learn from earlier mistakes were missed. The report outlines evidence of clinical care and decision-making that did not demonstrate the appropriate level of competence; a lack of joint decision-making and informed consent concerning place of birth; and examples where oxytocin (a drug used to induce labour) was used injudiciously and failures in CTG (the measurement of fetal heart rate and contractions) monitoring and interpretation. The report also describes a culture in which caesarean sections were discouraged and women “appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of delivery”. It turns out that from 2006 to 2018, caesarean rates at SaTH were between 8% and 12% below the England average. The review concludes that low rates were “perceived as the essence of good maternity care in the unit”. Beyond clinical procedures, there was a lack of kindness and compassion from some members of the maternity team. Women and their families’ concerns about their care were “dismissed or not listened to at all”. Serious incidents, including preventable deaths of babies, were not thoroughly investigated and there were repeated missed opportunities for learning and change to prevent future harm. In some cases, women were blamed for their loss, further intensifying their grief. As I flipped the pages of the Ockenden report, I was struck with a dreadful sense of deja vu. So many of the issues identified echoed those found in the Kirkup investigation, published more than five years ago into the systemic failures that led to my son’s death. Dr Bill Kirkup’s report describes poor multi-professional teamwork, a culture of keeping intervention rates low, an “over-zealous” approach to promoting “normal” childbirth, failures in risk assessment, serious deficiencies in clinical competence and repeated failures to properly investigate and learn from serious incidents of avoidable harm and death. The similarities do not end there. Just as it took a long and arduous battle by bereaved families to uncover the truth about events at Morecambe Bay trust, the Ockenden report only came about because of the extraordinary struggle of bereaved families. Without the efforts of the parents of Kate Stanton Davies and Pippa Griffiths, who both died just after their births at the trust in 2009 and 2016, the truth would remain untold. This week, I watch as government ministers and healthcare leaders make strong statements, promising that the findings will be a “watershed” moment for maternity services. But these are the very same promises made more than half a decade ago and recommendations remain unimplemented. To avoid this groundhog day, the government must develop better systems of oversight and implementation of inquiries, with input from harmed patients and families who are most vested in seeing change happen. No family should have to live through these painful memories again. No child should lose their life when answers to clinical and cultural failings are at hand. In the short term, the government can support safer maternity care by urgently investing in interventions that we already know make a difference, such as funding multi-professional staff training. Over the longer term, unless we address systemic issues prevalent in all services, progress will remain limited. The ideology of “normal childbirth” and a target-driven approach to lowering C-section rates has no place in modern maternity care and must be tackled once and for all. • James Titcombe is patient safety and policy consultant at Baby Lifeline