The Ockenden report into maternity services at Nottingham University Hospitals NHS Trust has found that mothers and babies were failed by long-running weaknesses in leadership, governance, culture, staffing and learning from mistakes.
The independent review, published today, examined maternity and neonatal care at NUH between 2012 and 2025. It was commissioned in June 2022 and considered cases involving mothers and babies who experienced loss, damage or harm during pregnancy, childbirth and the early postnatal period.
Donna Ockenden, chair of the Independent Maternity Review, said the report showed what could happen when leadership, governance and culture were not robust. She said poor practice was not investigated, learning was not integrated, and mothers and babies were failed by an organisation they should have been able to rely on during one of the most vulnerable periods of their lives.
The report says many of the issues described had been known about at NUH since at least 2010. These included insufficient staffing and funding across perinatal care, staff being unable to undertake basic and mandatory training, failures to listen to and believe mothers and fathers, and failures to investigate and learn from mistakes.
By the time the review closed in May 2025, nearly 2,500 families were involved. Their experiences occurred predominantly between 2012 and 2025. The review also heard from more than 800 current and former NUH staff, including clinicians, midwives, nurses and other healthcare professionals.
The report says families were the driving force behind the review and transformed it from a locally arranged review into the largest maternity inquiry in NHS history. Around 2,000 families whose cases were reviewed agreed to share their experiences, while a further 520 families provided feedback on the care they received.
Across the maternity pathway, families described experiences influenced by the quality of communication, whether care and information were consistent, whether they felt listened to and believed, how they were involved in decision-making, and how concerns were responded to.
Where those factors were present, families reported feeling reassured and supported. Where they were absent, experiences were described as confusing, distressing or disempowering.
The review found women’s experiences were shaped by loss of autonomy, inadequate communication, poor emotional and psychological safety, understaffing, delayed or missing observations and failures in escalation. It said these issues spanned more than a decade, suggesting they were deeply embedded and not confined to individual staff members or isolated incidents.
The report did identify examples of excellent and compassionate care. It found examples of strong multidisciplinary care in fetal medicine, ultrasound, maternal medicine and specialist pathways for women and babies at risk. It also found that anaesthetic care was of a high standard in the vast majority of reviewed cases, and that neonatal care was generally in line with national expectations, with many examples of good and exceptional practice.
However, those positive examples sat alongside repeated findings of systemic weakness. The review found long-standing problems in antenatal care, including variation in risk assessment, surveillance, documentation, communication and escalation. It identified triage as a particular weak link over the period covered, though it said there was evidence this had significantly improved since 2022.
In intrapartum care, the report identified recurring examples of suboptimal care in fetal monitoring, assessment and management of the latent phase of labour, and the recognition and management of post-partum haemorrhage. Common themes included unclear or absent guidelines, late adoption of national guidance, delayed escalation, inadequate training and oversight, and failure to learn from incidents and audits.
In postnatal care, the review examined care associated with 2,200 cases. It found that in most cases care was appropriate and often delivered with professionalism, compassion and effective multidisciplinary working. But it also documented recurring failures in core safety processes, including monitoring and escalation of maternal hypertension and clinical deterioration, recognition of the unwell or poorly feeding baby, discharge communication, and equitable care.
The review examined 27 maternal deaths between 2006 and 2024. Five were outside its terms of reference. Of the remaining 22 cases, reviewers identified failures in care that may have, or substantially impacted on, the outcome in six deaths. The report said 11 of the maternal deaths occurred to women living in the most deprived areas of the city and 14 involved women who were not white British.
The report also examined post-death care after distressing evidence relating to the care of baby Harriet Hawkins. It reviewed the care of 17 babies and one adult who died and found recurring failures to protect the dignity of the deceased, including poor mortuary care, dehumanising language, and inadequate arrangements for paediatric post-mortems.
On leadership and governance, the report says maternity and neonatal services do not operate in isolation, and that ultimate responsibility for quality and safety rests with the chief executive and board. It found known issues in maternity were at various times sidelined, ignored, deemed too difficult or treated as insufficiently important.
The review says six external reviews into maternity and neonatal care were commissioned between 2015 and 2022, all of which were extremely critical of culture, departmental and consultant behaviour, and governance. It concludes that challenges and weaknesses were known by service and corporate leaders as far back as at least 2015.
The report says NUH has taken measures since 2021 to strengthen visible clinical leadership, listening, accountability and staff engagement. It says evidence presented to the review indicates measurable progress in leadership, workforce development, culture, training and learning, and that the most recent CQC inspection published in 2026 recognised areas of improvement. However, it says further work is required to embed those changes and ensure they are sustained.
Donna Ockenden said safe, compassionate and equitable perinatal care was still achievable in Nottingham and across England, but only with an unwavering commitment to accountability, learning, transparency and kindness at every level of the system.
