Intended for healthcare professionals

  1. Marian Knight, professor of maternal and child population health1,
  2. Susanna Stanford, patient safety advocate2
  1. 1National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
  2. 2Northumberland, UK
  1. Correspondence to: M Knight Marian.knight{at}

Make this the last

The newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust1 is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored.2 Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby.3 Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care.

The Ockenden findings, and those of previous reports, must be framed within the context of enormous improvements in the safety of pregnancy over the 20th century because of advances in maternity care.4 Here perhaps lies part of the problem. The fact that pregnancy is now considered so safe seems to have led those managing services to forget that improved outcomes were achieved only by deploying sufficient …

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