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Key Findings from the Ockenden Report

Key findings:


  • A culture where mistakes were not investigated and a failure of external scrutiny


  • Parents were not listened to when they raised concerns about the care they receive


  • Where cases were examined, responses were described as lacking "transparency and honesty"


  • The trust failed to learn from its mistakes, leading to repeated and almost identical failures


  • A culture of bullying, anxiety and fear of speaking out among staff at the trust "that persisted to the current time"


  • Caesarean sections were discouraged, often leading to poor outcomes


There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved." Donna Ockenden

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