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