This review has examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents where medical records and family consent was gained. The Ockenden review team spoke to the families involved about their care and examined medical records. In addition, current and former members of staff completed surveys, were interviewed and contacted the review team to talk confidentially. The review team also scrutinised vast volumes of documentation provided by the Trust. The review found repeated failures in the quality of care and governance at the Trust throughout the last two decades, as well as failures from external bodies to effectively monitor the care provided. This final report identifies hundreds of cases where the Trust failed to undertake serious incident investigations, with even cases of death not being examined appropriately. The review found that where investigations did take place they did not meet the expected standards at that time and failed to identify areas for improvement in care. This report identifies more than 60 Local Actions for Learning for the Trust and another 15 key Immediate and Essential Actions to improve all maternity services in England, including financing a safe and sustainable maternity and neonatal workforce and ensuring training for the whole maternity team meets the needs of todays maternity services. We state that trust Boards must have oversight and understanding of their maternity services. Trust boards must ensure that they listen to and hear local families and their own staff.