A Black mother cradles her newborn baby who is asleep in her arms.

Ockenden report

by Communications team

We are pleased that the Ockenden report strongly endorses the government’s plan to establish our maternity investigations programme as a Special Health Authority, to continue providing ‘independent, standardised and family focussed investigations of maternity cases that provide families with answers’.

Our independent investigations:

  • ensure that mothers and families obtain a full account of what happened during their care and can contribute their story to the investigation
  • enable staff to share their views about problems and challenges to providing safe and effective maternity care
  • give trusts a clear picture of repeated patterns of risk, as well as evidence of where they are improving and where there is more improvement work required
  • provide insight about nationally recurrent themes that can support system-wide efforts to improve safety of maternity services.

HSIB has developed a standardised approach to investigation that identifies patient safety themes and feeds them back directly to trusts in a timely fashion. This helps maternity services to implement the required changes locally, encouraging trusts to take ownership of the solutions that are required. This could not be achieved without the voice of families in the investigation.

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