Major Maternity Review Highlights Systemic Issues
The most comprehensive maternity review ever undertaken within the National Health Service (NHS) is scheduled for publication today. This report is anticipated to detail extensive failures that contributed to the deaths of babies and caused avoidable harm at maternity units operated by Nottingham University Hospitals (NUH) NHS Trust.
Led by senior midwife Donna Ockenden, the review commenced in September 2022 and has gathered input from approximately 2,500 families and over 800 staff members. NUH Trust has already faced significant financial penalties, including millions in compensation and a record £1.6 million fine for maternity shortcomings related to three infant deaths in 2021.
Ongoing Investigations and Arrests
The publication of the review coincides with an ongoing police investigation, dubbed Operation Perth, initiated by Nottinghamshire Police in June 2023. This criminal inquiry is examining maternity failings at the trust, including a manslaughter case. The investigation runs parallel to the Ockenden review, which scrutinised care at Nottingham City Hospital and the Queen's Medical Centre.
Recently, two men, aged 55 and 59, were arrested on suspicion of misconduct in public office. These arrests, confirmed by the police on Monday, are connected to "operating practices in the mortuary service" at the trust and are separate from the corporate manslaughter investigation. Both individuals have since been released on bail under strict conditions.
Further investigations into allegations against individual NUH staff members are being conducted by healthcare regulators, including the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC).
Families' Fight for Justice
Among the first to highlight serious deficiencies at the trust were Sarah and Jack Hawkins. Their daughter, Harriet, was stillborn at City Hospital in April 2016. Despite an initial hospital review finding "no obvious fault," the couple, both former trust employees, pushed for an external review. This external assessment, published in January 2019, concluded that Harriet's death was "almost certainly preventable" due to a multitude of failings.
Jack Hawkins, 57, a former hospital consultant, expressed his dismay: "How on earth have we allowed it that there are 1,000 avoidable baby deaths in this country every year and, in a particular place, there are this many schools' worth of children missing or damaged beyond belief, and dead mums and damaged mums? How have we got here?"
Sarah Hawkins, 43, a former senior physiotherapist, added: "I know a lot of Nottingham families just want some form of justice, to clear their children's name, to know that the harm that was caused wasn't their fault." The couple's legal case against the trust was settled out of court for £2.8 million, believed to be the largest payout for a stillbirth clinical negligence case.
Another tragic case involves Gary and Sarah Andrews, whose daughter Wynter died just 23 minutes after birth in 2019. NUH was fined £800,000 in January 2023 after admitting failures in their care. Gary Andrews, 38, stated, "The report being published today needs to serve as a wake-up call to the NHS locally and nationally, that what's gone on before cannot be allowed to continue."
Regulatory Actions
The NMC is currently assessing 96 "fitness to practise" cases related to maternity care at NUH, with 15 undergoing full investigation. One midwife has been investigated and is awaiting a decision, with an interim order preventing them from practising. The GMC is reviewing 62 cases concerning doctors, with 53 at an initial stage. GMC investigators are also examining over 300 information reports forwarded by the Ockenden review.
The Ockenden review, which spans the period from April 2012 to May 2025, has spurred a national inquiry into maternity failings across the NHS.
Source: Largest maternity review in NHS history to be published