Systemic Failings Identified in Nottingham Maternity Care
A significant independent review, the largest of its kind in NHS history, has concluded that more than 500 mothers and babies suffered preventable harm or death due to deep-seated issues at Nottingham University Hospitals (NUH) NHS Trust. The inquiry, led by senior midwife Donna Ockenden, found that the trust's leadership was aware of serious problems within its maternity department for years but failed to implement necessary changes.
Upon the report's publication, Ockenden emphasized the profound cost of a failing system, stating, "This is a report about how a system failed, and what it costs when it fails. It costs lives, futures and families, everything." The review indicated that different care approaches might have altered the outcomes for 260 babies who either died or were harmed.
Scope of the Investigation and Key Findings
The review, initiated in 2022, gathered contributions from approximately 2,500 families and over 800 staff members. However, Ockenden noted "gaps" in the information due to some senior leaders declining to participate in the inquiry. Of 66 former and current senior colleagues approached by the trust's chief executive, 37 came forward, with 35 being interviewed.
Experts involved in the review identified potentially avoidable outcomes in 444 maternity cases and 76 neonatal cases examined up to May 2025. These 520 cases were graded for harm, with grade three indicating "major concerns" and grade two suggesting "sub-optimal care" where different management could have made a difference.
Recommendations and Accountability Measures
The reluctance of some management personnel to engage with the review prompted the government to announce an extension of Martha's Rule to enhance accountability and safety in maternity and neonatal settings. Furthermore, new measures are being considered to compel current and former NHS staff to provide evidence in future maternity reviews, potentially facing up to two years in prison for non-compliance, though the enforcement mechanism remains unclear.
Ockenden presented the findings in Nottingham, reiterating that many of the identified problems at NUH, such as insufficient staffing and inadequate staff training, had been known since at least 2010. She also highlighted a "persistent failure to listen to and believe mothers and fathers" and a lack of thorough investigation into mistakes.
Disturbing accounts from the report included instances where women's consent was not sought during labor, and staff interactions were at times described as "cruel." Examples included women being told to "pull themselves together" or to "wait their turn" during labor.
Family Testimonies and Calls for Justice
Dr. Jack Hawkins, whose daughter Harriet was stillborn at Nottingham City Hospital in 2016, spoke at a press conference following the report's release. He stressed the importance of taking the review's identified learning actions with "utmost seriousness." He shared his family's direct experience of dismissed concerns, untruths, and the hospital's failure to ensure their loved one's safety.
Sarah Hawkins, Harriet's mother and a whistleblower, expressed feeling betrayed by those entrusted with her care. As a senior physiotherapist, she stated, "After Harriet died - the cover-up was horrific, we knew this because we knew the system." Dr. Jack Hawkins called for a statutory public inquiry, a request that Health Secretary James Murray stated would be considered, assuring that "no options are off the table."
Murray, who met with affected families, conveyed his profound sadness over their experiences and committed that "the government will act." Following the report's publication, it was confirmed that Martha's Rule, which allows patients to request an urgent review of their care, would be extended to all maternity units.
Trust's Response and Commitment to Change
In response to the review, NUH chairman Nick Carver and chief executive Anthony May issued an open letter, offering an "unreserved" apology to the women and families who suffered harm, loss, trauma, or distress. They acknowledged that trust is earned through actions and pledged to reflect on the report with humility and determination.
The letter affirmed the trust's commitment to working with families on a meaningful apology that reflects the review's findings and their dedication to lasting improvements in maternity services.
Source: Babies and mothers died after 'systemic and sustained' failings, largest NHS maternity review finds