A shocking catalogue of failures within maternity services at Nottingham University Hospitals NHS Trust has been laid bare in a harrowing 400-page report by Donna Ockenden. The review, published on Wednesday, highlights a range of critical issues that have had devastating consequences for patients and their families, including the tragic death of baby Harriet Hawkins in 2016. As our health correspondent Dr. Emma Clarke explains, this is not an isolated incident – it's part of a broader problem affecting maternity care across England.
The report outlines approximately 100 action points, adding to more than 700 recommendations from earlier reports on maternity care. The sheer volume of these recommendations underscores the significant challenge of implementation, and campaigners are calling for urgent action. Next week, Valerie Amos is expected to contribute further findings from her own investigation into maternity care. The political commitment to addressing these issues remains paramount, but with recent developments threatening to derail progress – including the resignation of Wes Streeting, who had pledged to chair a new taskforce – there are concerns that momentum may be lost.
One of the most pressing concerns is safe staffing levels, with an alarming nine out of ten midwives reporting understaffed wards. Experts, including Professor Alison Leary, deputy president of the Royal College of Nursing, advocate for legally mandated minimum nurse-patient ratios to prevent further tragedies. However, workforce shortages were not the sole contributing factor – a particularly troubling revelation is the sustained duration of poor services over many years. As Dr Ockenden's report highlights, a change in leadership in 2017 arguably exacerbated the problems, while a 2006 merger led to two separate maternity units operating in isolation with insular and sometimes toxic cultures.
The Trust has faced significant penalties, paying nearly £2.5 million in fines in 2023 and 2025 following Care Quality Commission investigations into care failures, including those related to baby Wynter Andrews. A police inquiry, known as Operation Perth, is currently investigating potential corporate manslaughter charges and has already made two arrests linked to mortuary services. While local investigations are underway, some campaigners argue that they are insufficient and are calling for a statutory public inquiry instead.