The independent review led by senior midwife Donna Ockenden into maternity services at Nottingham University Hospitals NHS Trust has been published today, exposing a decade of systemic failures that resulted in hundreds of mothers and babies dying or suffering serious harm. The report, the largest of its kind in NHS history, examines more than 2,500 cases spanning from 2012 to 2025 and paints a picture of a toxic culture where warnings were ignored and patient safety was repeatedly compromised.
Background to the Nottingham Maternity Scandal
Concerns about maternity care at Nottingham University Hospitals NHS Trust, which operates the Queen's Medical Centre and Nottingham City Hospital, have been building for years. Families affected by stillbirths, neonatal deaths, maternal deaths, and life-changing injuries began raising alarms long before the full scale of the issues became public. In 2022, following pressure from bereaved families, NHS England commissioned an independent review to replace an earlier regional effort. Donna Ockenden, who previously led a major inquiry into maternity failings at Shrewsbury and Telford Hospital NHS Trust, was appointed to chair the process.
The review was established to listen directly to families and staff, assess the quality of care, and identify lessons that could prevent future tragedies. It quickly grew in scope, ultimately reviewing cases involving 2,505 families and gathering evidence from approximately 850 current and former staff members. The period under scrutiny covers care provided between 1 April 2012 and 31 May 2025.
Scope and Scale of the Ockenden Review
Unlike previous investigations, this review represents the most comprehensive examination of maternity services ever undertaken within the NHS. It focused on incidents including stillbirths, neonatal deaths, brain injuries to babies, and maternal deaths or serious injuries. The final document exceeds 350 pages and incorporates personalised feedback to families alongside detailed analysis of clinical care, governance, and organisational culture.
The review team, comprising experienced doctors and midwives with no connection to the trust, assessed each case against national standards and best practice. This methodical approach allowed for the identification of recurring patterns rather than isolated incidents. The closure of the review to new cases in May 2025 enabled the team to complete its work and prepare the report for publication.
Key Findings: Systemic and Cultural Failings
The report details horrendous failings across multiple areas of maternity care. A senior source familiar with the conclusions described them as appalling, highlighting a catalogue of poor behaviour by staff over many years. Among the most disturbing revelations is evidence of racism towards mothers from minority ethnic backgrounds, with some women reporting dismissive attitudes and unequal treatment during labour and postnatal care.
Other systemic issues include a culture that prioritised natural childbirth over clinical safety, leading to delayed interventions in high-risk situations. Governance structures failed to ensure proper investigation of incidents, and opportunities to learn from mistakes were routinely missed. Staffing levels were frequently inadequate, contributing to errors and poor outcomes. The review found that concerns raised by both families and frontline staff were often not escalated effectively or acted upon by senior management.
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Impact on Families and Human Cost
Behind the statistics lie countless personal tragedies. Families have described experiences of being gaslit, having their concerns dismissed, and living with the lifelong consequences of avoidable harm. Some babies suffered brain injuries that could have been prevented with timely action, while others did not survive. Mothers endured traumatic births and, in some cases, life-threatening complications that were not properly managed.
The Nottingham Maternity Families Group has been vocal in demanding accountability. In statements ahead of publication, the group emphasised that the suffering endured by families must lead to meaningful change rather than another set of recommendations left unimplemented. Many families have waited years for answers, and the report provides a long-overdue acknowledgment of their experiences.
Institutional and Regulatory Responses
Nottingham University Hospitals NHS Trust has acknowledged shortcomings and pointed to improvements in staffing and culture since leadership changes in 2022. Chief executive Anthony May has issued apologies to affected families. However, the Care Quality Commission, following an inspection in May 2025, rated maternity services at both hospitals as requiring improvement despite noting some progress.
The Nursing and Midwifery Council is investigating 96 midwives and nurses from the trust for alleged misconduct, with 15 cases under full investigation and one midwife currently suspended. Nottinghamshire Police continue their Operation Perth inquiry, which is considering whether the trust could face corporate manslaughter charges in relation to at least 200 families.
Health Secretary James Murray has met with affected families and vowed that recommendations will not gather dust. He stressed the need for tangible action plans across the NHS.
Broader Implications for NHS Maternity Services
The problems identified in Nottingham are not isolated. Previous reviews, including the earlier Ockenden report on Shrewsbury and Telford, revealed similar patterns of poor governance, inadequate staffing, and failure to listen to families. A government-commissioned national inquiry led by Valerie Amos is also due to report soon, adding further scrutiny to maternity care across England.
Campaigners and families are calling for a full statutory public inquiry to examine maternity and neonatal services nationwide. Such an inquiry would have powers to compel witnesses, addressing limitations faced by the Ockenden review. The Royal College of Midwives has highlighted ongoing staffing crises, with surveys showing that unsafe staffing levels affect care in the majority of units.
Recommendations and Path to Reform
While the full list of essential actions will be detailed in the report, expectations centre on stronger clinical governance, improved escalation procedures, better multidisciplinary training, and robust mechanisms for listening to families and staff. There are calls for increased investment in maternity services to ensure safe staffing levels and for greater accountability at board level.
Ockenden herself has noted an improving culture at the trust in 2026 but emphasised that significant work remains. Implementation will require sustained commitment from NHS England, the Department of Health and Social Care, and individual trusts. Previous recommendations from maternity reviews have often been only partially adopted, underscoring the need for rigorous monitoring and follow-through.
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Future Outlook and Ongoing Scrutiny
The publication of this report marks a critical moment for maternity safety in the United Kingdom. With police investigations continuing and regulatory bodies actively reviewing individual practitioners, further developments are expected. The government has indicated it is considering a national public inquiry, which could provide the comprehensive overhaul many families believe is necessary.
Trusts across the country will be examining their own practices in light of these findings. Improved transparency, better data sharing on incidents, and a renewed focus on patient-centred care are likely to feature prominently in future policy discussions. Families affected by the Nottingham failings continue to advocate for justice and systemic change that prevents similar tragedies elsewhere.
Supporting Affected Families and Accessing Help
For those impacted by maternity failings, support is available through specialist organisations and legal channels. Clinical negligence solicitors can provide advice on potential claims, while bereavement and trauma support services offer emotional assistance. The Nottingham Maternity Families Group remains a key resource for peer support and collective advocacy.
Anyone concerned about their own experience or that of a loved one is encouraged to contact the trust directly or seek independent advice. The full Ockenden report will be available via official NHS channels following publication.