A three‑year review has revealed that 520 mothers and babies at Nottingham University Hospitals NHS Trust (NUH) suffered harm or death, prompting fresh demands for a public inquiry into maternity care across England.
The independent report, led by maternity safety expert Donna Ockenden, found 444 women and 76 newborns experienced “potentially avoidable” outcomes. It covered maternity services from 2012 to 2025 and has been described by Health Secretary James Murray as “horrific” and “chilling”.
Murray said families endured “dangerously and tragically deficient care at almost every turn” and that “the NHS failed them catastrophically.” He expressed being “devastated” and “heartbroken” by Ockenden’s 401‑page account of “neglect, incompetence, racism, discrimination, contempt and harassment” suffered by many women.
Ockenden’s investigation highlighted systemic failures at both of NUH’s hospitals—Queen’s Medical Centre and Nottingham City Hospital. Key issues included:
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A “bullying and toxic culture” that persisted for years and impeded improvements.
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Repeated warnings to managers and senior leaders about serious maternity problems that went unaddressed.
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A practice of “not admitting women who were seeking admission in labour,” despite the dangers.
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Chronic understaffing that left units unable to cope with birth volume and complexity.
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One baby who died early in gestation was mistakenly disposed of as clinical waste after a post‑mortem.
Clinical failures were also documented. Staff often failed to listen to women or act promptly on concerns, leading to delays in scans and inadequate fetal monitoring. Misinterpretation of CTG (cardiotocography) traces, failure to recognize fetal distress, and delayed escalation of cases by midwives contributed to severe neonatal injury, stillbirth and neonatal death.
The review examined 27 maternal deaths between 2006 and 2024, identifying care failures that may have contributed to six of these deaths. It also looked at 31 newborn deaths, concluding that inadequate care likely could have prevented harm.
Evidence was gathered from 2,536 families and 838 current or former NUH staff. Many senior executives and NHS commissioning leaders declined to engage, with only four of 14 NHS leaders contacted providing input.
The Nottingham Maternity Families group, representing about 600 harmed or bereaved families, has called on Prime Minister Keir Starmer to launch a statutory public inquiry to examine failings across the entire NHS. Health Secretary Murray indicated the government is considering the request, stating “nothing should be taken off the table at this stage,” though he noted that not all affected families support an inquiry.
The government announced several reforms. Martha’s Rule—granting patients the right to an independent second opinion—will be introduced in every maternity unit in England, as recommended by Ockenden. Additionally, NHS staff who refuse to give evidence to maternity inquiries may face up to two years in prison, aimed at breaking a “culture of silence” around care failures.
Ockenden is also leading reviews of alleged systemic failures in maternity services in Leeds and Sussex. The NUH chief executive, Anthony May, and chair, Nick Carver, issued an apology to affected families, stating, “We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services.”
Murray pledged that the government and NHS leaders will “deliver lasting change” to improve maternity services nationwide, with Ockenden’s findings guiding a new action plan being developed by the Department of Health and Social Care’s maternity taskforce.
