The Ockenden report says serious weaknesses in Nottingham University Hospitals NHS Trust’s maternity services were known for years before meaningful change was made.
The independent review found long-standing and systemic failures in maternity governance, marked by chronic under-resourcing, unclear leadership structures, ineffective governance processes, barriers to escalation and failure to learn in a timely way from incidents.
It says the consequences were significant: investigations were delayed, similar incidents recurred, and families experienced prolonged uncertainty and avoidable harm. Staff described burnout, illness and missed opportunities to improve quality and patient safety.
The review, published today, examined maternity and neonatal care at NUH between 2012 and 2025. It says many of the issues described in the report had been known about at NUH since at least 2010, including insufficient staffing and funding, staff being unable to undertake mandatory training, failure to listen to and believe mothers and fathers, and failure to investigate and learn from mistakes.
On corporate leadership, the report says maternity and neonatal services sit within wider Trust division and corporate structures, with ultimate responsibility for quality and safety resting with the chief executive and board.
After reviewing Trust minutes and reports, external reviews and staff testimonies, the review concluded that known issues, challenges and failings in maternity were at various times sidelined, ignored, treated as too difficult, or judged to be of insufficient priority.
The report says six external reviews were commissioned into maternity and neonatal care at NUH between 2015 and 2022. It says all were extremely critical of culture, departmental and consultant behaviour and overall governance. The review concludes that the challenges and weaknesses identified were known by service and corporate leaders as far back as at least 2015.
The review identified several Board failings, including significant issues not being referred to or discussed by the Board, Board members showing insufficient curiosity to challenge, and a culture of leaving major operational issues within sub-committees.
It also found evidence that within the executive team and senior maternity management there were decisions not to escalate matters to the Board, and that leaders provided reassurance rather than assurance that problems were being dealt with. The report says midwifery leaders did not have direct access to the Board, creating a disconnect between strategic direction and operational management.
The report sets out a timeline of concerns dating back to the early 2010s. It says Nottingham University Hospitals was formed in 2006 through the merger of Queen’s Medical Centre and Nottingham City Hospital, and that during the following two decades its maternity and neonatal services were increasingly scrutinised because of governance, safety and cultural concerns.
A confidential internal report in 2012 raised concerns about leadership capability and organisational culture at Board and executive level. Around the same time, the Trust’s Board Quality Committee identified a backlog of Serious Incidents across the organisation, indicating failings in the timely investigation and resolution of patient safety events.
A CQC inspection in November 2013 identified NUH as a high-risk Trust. The report says the inspection highlighted midwifery staff shortages, increasing safety problems and mortality alerts, while concerns about outcomes were not consistently acknowledged within obstetric leadership.
By 2015, concerns had moved beyond early warning signs and were being raised more explicitly within governance structures. Evidence presented to the Trust Board indicated ongoing safety concerns, including workforce pressures, cultural issues and weaknesses in escalation processes. The report says assurances were nevertheless provided that clinical outcomes were satisfactory and that services were operating safely.
The report also refers to a 2018 external performance audit by MSB Consulting, which reviewed culture and issues highlighted in high-profile clinical incidents. It identified poor leadership, culture and communications, and noted that inappropriate behaviour was tolerated.
Later in 2018, more than 50 maternity staff signed a letter to the NUH Board chair raising concerns about staffing and safety. NUH then used an independent national safety climate metric, scoring considerably lower than national NHS benchmarks in all domains.
The review says staff voices and external reviews pointed to prolonged maternity leadership instability, fragmented governance arrangements and a workplace culture characterised by fear, disengagement and lack of psychological safety.
Staff reported long-standing cultural challenges, including hierarchy, bullying, nepotism, aggressive behaviour, inconsistent professional values and poor psychological safety. More than 40 per cent of staff who engaged with the review said they had either witnessed or personally experienced bullying by managers or other colleagues as a regular part of their working environment.
Staffing was the most serious and pressing issue raised by staff, with only 11 per cent reporting sufficient staff for the workload and 59 per cent saying staff regularly worked longer hours than was best for service quality.
The report does acknowledge more recent improvement work. It says that since 2021 NUH has implemented deliberate measures to strengthen visible clinical leadership within maternity services. Work to change and improve culture included regular reviews of Freedom to Speak Up reports, Datix insights, staff surveys and quarterly Listening Forums led by the Director of Midwifery.
Evidence presented through the review indicated measurable progress in leadership, workforce development, culture, training and learning. The most recent CQC inspection, published in 2026, recognised areas of improvement.
However, the report says further work is required to embed those changes and ensure they are sustained.
