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A comprehensive review into maternity care at Nottingham University Hospitals (NUH) NHS Trust has revealed that over 500 mothers and babies experienced preventable harm or death due to systemic failures in the maternity services. The investigation, led by senior midwife Donna Ockenden, represents the largest inquiry of its kind within NHS history. It found evidence that leadership at NUH had long been aware of serious issues within the maternity department but did not take sufficient corrective measures.
The inquiry, which began in 2022, involved contributions from around 2,500 families and more than 800 staff members. Despite these efforts, there were notable gaps in information as several senior leaders chose not to engage with the review process. Of 66 senior staff asked to participate, 37 came forward, with 35 interviewed. Experts assessed 520 cases, including 444 maternity and 76 neonatal instances, identifying 260 babies whose outcomes might have improved with different care. Within these, 155 infants died while 105 suffered serious injuries attributable to substandard treatment. Harm was categorized in grades two and three, indicating sub-optimal to major concerns regarding clinical management.
Ockenden presented the findings at an event in Nottingham, highlighting issues such as inadequate staffing, failure to provide mandatory training to staff, and a troubling culture of not listening to or believing mothers and fathers. She emphasized that women’s consent was often not obtained during labor, and some interactions with care providers were described as “cruel”. Examples given included women being told to “pull themselves together” or to “wait their turn” because other patients required attention. The senior midwife noted that many of these problems had existed at NUH since at least 2010, reflecting a prolonged neglect of critical maternity safety concerns.
Following the report’s release, reactions from families and officials were profound. Dr Jack Hawkins, whose daughter was stillborn at Nottingham City Hospital, described the hospital’s record as one where “the hospital frequently failed to keep our loved ones safe” and called for a statutory public inquiry. Sarah Hawkins, Harriet’s mother and a whistleblower in the scandal, expressed deep feelings of betrayal, stating: “We dedicated our careers to the NHS—I thought I would trust my colleagues… After Harriet died—the cover-up was horrific.” Health Secretary James Murray, addressing Parliament, acknowledged the severity of the failings and confirmed that no options were off the table as the government prepared to act, including extending Martha’s Rule, which guarantees rapid reviews of patient care, to maternity services. In response, NUH’s chairman Nick Carver and chief executive Anthony May issued a public apology, pledging to collaborate with families on meaningful apologies and committed to sustained improvements to rebuild trust
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