A comprehensive review into maternity services at Nottingham University Hospitals (NUH) NHS Trust has exposed “deeply embedded systemic failures” that contributed to potentially avoidable harm and deaths for hundreds of mothers and babies. The inquiry, led by senior midwife Donna Ockenden, is the largest of its kind in NHS history and paints a stark picture of neglected concerns and a detrimental workplace environment.
The report, which involved contributions from approximately 2,500 families and over 800 staff members, concluded that 444 maternity cases and 76 neonatal cases up to May 2025 involved outcomes that could have been prevented. These cases were categorised with significant or major concerns regarding the care provided. Specifically, the review team identified that different care might have altered the outcome for 260 babies who either died or were seriously harmed. This figure includes 155 baby deaths and 105 instances of serious injury, some resulting in permanent brain damage, attributed to substandard care.
The findings indicate that adverse outcomes were rarely due to a single failing, but rather a combination of factors. These included inadequate monitoring of babies, misinterpretation of heart monitoring, a failure to recognise foetal distress during labour, and a lack of escalation to senior medical staff when necessary. Ms Ockenden further criticised the existing systems of oversight for maternity care, deeming many of them “no longer fit for purpose.”
A significant aspect of the review highlighted a “bullying and toxic culture” within the trust over many years. Accounts from mothers included being told to “pull themselves together” during labour or to “wait their turn.” Staff also described a pervasive “tribalism” and a “Nottingham way” of operating, where bad behaviours were normalised and professional boundaries blurred. Leadership instability was cited as a major contributing factor to the decline in quality and safety, with frequent turnover in senior maternity leadership and operational roles between 2017 and 2021.
Crucially, the report states that many of the problems detailed, such as insufficient staffing and a lack of mandatory training, have been known to the trust since “at least 2010.” Despite this long-standing awareness, sufficient action was not taken to prevent further harm and deaths. The review also found that concerns raised by women and families were often dismissed or minimised, hindering opportunities for early identification of deterioration and timely intervention.
The implications of this report are profound, not only for NUH Trust but for maternity services across England. Ms Ockenden expressed hope that her conclusions would “drive real and lasting change.” The recommendations set out in the review are intended to instigate improvements within perinatal services at Nottingham University Hospitals NHS Trust and serve as a blueprint for enhancing maternity care nationally.
What this means for you: This report underscores the critical importance of patient advocacy and the need for robust oversight in healthcare settings. If you have concerns about your maternity care or that of a loved one, it is vital to speak up. Always consult your GP or call NHS 111 if you have medical concerns.
Source: Donna Ockenden Review