The publication of the final report of the Independent Review of Maternity Services at Shrewsbury and Telford Hospital NHS Trust (SaTH) must be a watershed moment for maternity safety in the UK.

Every mother has the right to expect safe maternity care for herself and her baby.  

It is essential that the Government supports Trusts to implement the immediate and essential actions laid out by Donna Ockenden, to save lives and prevent avoidable deaths and suffering for families. 

A tragedy of this scale must never be allowed to happen again. Time and again reports have told us what’s going wrong in failing maternity units. 

Action is now urgently needed at every level throughout the healthcare system, from clinical training to management ethos, and properly resourced support for midwives and other frontline professionals.  

And this can be achieved by building a healthcare system and culture that is designed to spot problems early, that supports a continual cycle of evidence gathering, learning and professional training, and drives improvements in maternity safety.  

Listening to parents saves lives  

Saving babies’ lives is an absolute priority for Sands, and we know that listening to parents and families is crucial so that this evidence leads to learning that drives changes in practice. 

This review has been carried out with parents at its heart and today’s report is clear that SaTH did not listen to families and did not learn from mistakes.  

We must change the culture that has silenced bereaved parents and prevented lessons being learned, so that no babies die because of avoidable mistakes.

If the UK is to be the safest place in the world to have a baby, we need a culture of openness where human errors or systemic failings can be acknowledged, and lessons learned by Trusts.

Clea Harmer, Sands Chief Executive


It is shocking to learn that 40% of term stillbirths between 2011 and 2019 at SaTH had not had an investigation, and even where an investigation had taken place only 36% met standards and 33% had parents involved appropriately.

We must ensure that bereaved parents' voices are heard by decision makers in the NHS and government so that their experiences help improve safety in maternity and neonatal care. 

Crucially, hospitals need enough staff, resources and support to do this effectively. Trusts which are struggling must be identified earlier and offered support so that babies and mothers are kept safe and well.   

Our message to healthcare professionals at every level of the NHS is that we are here to support you and help you to provide the best bereavement care. 


Sands training and education can make sure you’re up-to-date with developments, both in bereavement care so parents whose baby has died are well looked-after, and involving those parents in reviews to learn lessons that can save future lives. 

We are working hard to save babies’ lives

This year we formed a Joint Policy Unit with Tommy’s working together towards halving the number of UK baby deaths by ensuring decision makers have access to up-to-date information, and maternity policy is informed by robust evidence. The Unit will be monitoring how the recommendations and essential actions identified in this report are implemented to support the maternity system to achieve this. 

Sands is a member of the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries) and their annual reports and confidential enquiries improve understanding of where and why babies die. 

Sands helped develop the Perinatal Mortality Review Tool to ensure that every baby's death is reviewed. The inclusion of parents must be a central part of these reviews. Learning from them is an integral part of improving safety in care and in preventing tragedies such as Shrewsbury and Telford. 

It is essential that the voice of bereaved parents is at the heart of any investigations related to care. We ensure that bereaved parents' voices are heard by decision makers in the NHS and government so that their experiences help improve safety in maternity and neonatal care. 

Parents have the greatest stake, and a unique insight, in understanding what happened when something goes wrong, and why their baby died; they want learning from investigations to result in swift and effective change so that nobody else goes through this pain. 

We are here for parents and families

Today’s news about the events within the Shrewsbury and Telford Hospitals NHS Trust will have been very painful for those who have been affected directly and anyone affected by pregnancy loss or the death of a baby. We are here to support anyone who needs us. 

We are here to offer bereavement support to all those parents and families affected, who will be going through unbearable pain following their loss.

Clea Harmer, Sands Chief Executive

This final Ockenden report is the end of a review that began five years ago after the families of two babies, Kate Stanton-Davies and Pippa Griffiths, who died under the trust’s care, raised concerns about their cases and 21 others. 

For the families involved this is not the end. They will never forget their precious babies and these families must not be forgotten as the official enquiry closes.  

It is their stories, and the stories of all the other families that have been affected, that shines a light on the devastation of the families at the heart of this tragedy.  

Since 2020 Sands has been part of a dedicated service to support the families whose babies died while under the care of Shrewsbury and Telford Hospital NHS Trust, working alongside the specialist psychological therapies made available by the review team. 

It’s good to see that the report acknowledges the importance of bereavement care and the National Bereavement Care Pathway (NBCP). Sands has worked closely with Shrewsbury and Telford Hospitals Trust to improve the bereavement care they provide and we want every NHS Trust and Board across the UK to implement the NBCP. 

If you or anyone you know have been affected by pregnancy loss or the death of a baby, we are here to offer support

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