A comprehensive independent review into maternity services at Nottingham University Hospitals (NUH) NHS Trust has uncovered that over 500 mothers and babies experienced avoidable harm or death due to widespread systemic failings. The inquiry, led by senior midwife Donna Ockenden and the largest of its kind in NHS history, detailed a "bullying and toxic culture" within the trust's maternity departments.
The report, published on Wednesday, revealed that leaders at NUH were aware of significant problems within their maternity services for many years, dating back to at least 2010, but failed to implement effective changes. The review team concluded that different medical management could have altered the outcomes for 260 babies who either died or suffered serious injury due to substandard care. This includes 155 babies who died and 105 who sustained serious injuries.
The review, which commenced in 2022, involved contributions from approximately 2,500 families and over 800 members of staff. It identified 520 cases of harm to mothers and babies up to May 2025 that were graded as either 'sub-optimal' or 'major concerns' regarding the care provided. These included cases where sub-optimal care might have made a difference to the outcome, and those where different management would reasonably have been expected to make a difference.
Key issues highlighted in the report included insufficient staffing levels, a lack of essential and mandatory staff training, and a persistent failure to listen to and believe mothers and fathers. Disturbingly, the review also found instances where women's consent was not sought during labour, and some staff interactions were described as "cruel," with mothers being told to "pull themselves together" or "wait their turn."
Further serious failings were identified in post-death care, encompassing concerns about loss of dignity, poor mortuary procedures, ineffective identification systems, and inappropriate communication. The report cited a distressing incident in 2019 where a very early gestation baby was inadvertently disposed of as clinical waste, and another in 2022 involving the release of the wrong baby to a funeral director. These incidents underscore a profound lack of care and respect.
A significant challenge for the review was the non-engagement of some former and current senior leaders. Out of 66 senior colleagues approached, only 37 came forward, with 35 being interviewed. This lack of accountability prompted the government to announce an extension of Martha's Rule and measures to compel current and former NHS staff to provide evidence in future maternity reviews, with potential penalties for non-compliance.