A report castigates the National Health Service

ONE BABY died at 21 minutes of age; another, at 34. A third made it to six hours, and a fourth to six days. The skull of one baby was crushed. The skull of another, after nine attempts at delivery, at times with forceps, was fractured on both sides.

The final Ockenden Report, published on March 30th after years of campaigning by bereaved parents (two are pictured), does not make for easy reading. It looks at the maternity care provided by Shrewsbury and Telford Hospital NHS Trust over two decades. Its 250 pages are unprecedented in NHS history, in length and scale—and, arguably, in condemnatory tone. Although finely detailed—noting the strength of this mother’s contractions; when that mother’s waters broke; when this baby ceased breathing—its chief finding is simple. This report, writes Donna Ockenden, the midwife who led it, “is about an NHS maternity service that failed”.