Care Quality Commission (CQC) statement 

Thu 10th December, 2020

Care Quality Commission (CQC) statement following the publication of the first report

Professor Ted Baker, Chief Inspector of Hospitals, said:  
“The death or injury of a new baby or mother is a devastating tragedy and something that everyone working in the health and care system must do all they can to prevent.   
 “The emerging findings from Donna Ockenden’s review make for difficult reading. Limited oversight of risk, insufficient safety training for staff, poor communication with families, and a lack of robust investigation or learning when errors were made. Sadly, these are all themes that have been identified before, but yet again it has taken the repeated persistence of campaigning families and patients to bring them to the fore.  

“The continued national focus on the safety of maternity services is welcome – and we are seeing some positive change. However, the progress made does not yet meet the scale of the challenge.  

“As we set out in our Getting Safer Faster briefing earlier this year, there needs to be concerted national action and accelerated efforts to ensure that improvements in safety are achieved with the urgency required.  A major factor in this is the need to drive a change in culture that means the voices of staff, patients and their families are listened to and acted on. Without this shift we will not move forward. 
 “We welcome the recommendations set out by Donna Ockenden and her team and will monitor their implementation by the Trust, as well as working with the Department of Health and Social Care, NHS England/Improvement and wider system partners to play our part in supporting implementation.