The Ockenden report into maternity services at Nottingham University Hospitals NHS Trust has paid tribute to the Nottingham families whose determination led to the largest maternity inquiry in NHS history.
Donna Ockenden, chair of the Independent Maternity Review, said the review owed its origins to a courageous group of Nottingham families who endured grief and pain following death and injury during childbirth.
The report names a number of families whose experiences helped bring the review about, including Harriet Hawkins and her parents Jack and Sarah; Wynter Andrews and her parents Gary and Sarah; Baby Ladybird and her parents Carly Wesson and Carl Everson; Quinn Lias Parker and his parents Emmie Studencki and Ryan Parker; Kouper Needham and his parents Dave and Natalie; Teddy and his parents Kimberley Errington and Jason; Caitlin Gwinnett-Stringer and her parents Emily and Darryl; and Felicity Benyon.
The report says these families came together through shared experiences of harm and bereavement and were determined that maternity services should be improved both in Nottingham and across the country.
When the review was agreed by former Health Secretary Sir Sajid Javid, they were a small group of families seeking accountability and answers for themselves and for others they knew had experienced harm. By the time the review closed in May 2025, nearly 2,500 families were involved, with experiences occurring predominantly between 2012 and 2025.
Donna Ockenden said the families had shown “extraordinary courage, dignity and determination” and that their voices must now become the catalyst for lasting national change.
The report’s acknowledgements say more than 2,500 families came forward to tell the review team what happened to them during their maternity and neonatal journey at NUH. It says participation required many parents and families to revisit the most painful moments of their lives, including the deaths of babies, life-changing injuries and serious harm suffered by mothers.
The report says families spoke with courage, honesty and dignity about events that had a profound and lasting impact on their lives. Their involvement, it adds, was central to the review’s work.
It says thousands of families entrusted the review team with their accounts not only to seek answers, but also because they wanted to prevent others enduring similar circumstances. Their experiences, and the lives of their babies and partners, were intended to lead to learning, accountability and meaningful change.
The review gives particular recognition to the families who set up and supported the Affected Families Group, saying they worked to ensure the review happened and continued to make sure families remained at the heart of the investigation.
The report says the scale and depth of evidence gathered provided insight into patterns of harm, organisational culture, inequalities in maternity provision, and care following the death of babies or mothers. It also identified concerns relating to bereavement support and after-death care.
The review begins with the experience of baby Harriet Hawkins and her parents, Jack and Sarah. Harriet died just before her birth on April 16, 2016. The report says that after three internal investigations, a fourth external review published in December 2017 confirmed that her death was avoidable and was due to poor care her mother received in the latter stages of pregnancy.
The report says Jack and Sarah Hawkins’ search for justice, accountability, truthful answers and assurance that things would change was met by almost ten years of “obfuscation, delay, callousness and incompetence”. It says the Hawkins family’s experience was unique and instructive because “whatever could go wrong for them did”.
Families more widely described experiences shaped by the quality of communication, whether care was consistent, whether they felt listened to and believed, their involvement in decision-making and how their concerns were handled.
Where these elements were present, families said they felt reassured and supported. Where they were missing, experiences were often confusing, distressing or disempowering.
Women described loss of autonomy, inadequate communication, poor emotional and psychological safety, understaffing, delayed or missing observations and failures in escalation. The report says these issues spanned more than a decade, showing they were deeply embedded rather than isolated.
The review also identified markers of psychological distress among families who shared their experiences. Key themes associated with psychological harm included poor communication, lack of agency, lack of transparency, clinical mismanagement, lack of compassion and failure to recognise vulnerability and physical trauma with long-term health consequences.
The report says all families included in the review were offered support through a Family Psychological Support Service, providing referral to a range of therapeutic approaches and links with local support services.
It concludes that the lost and forever changed lives of mothers, fathers and babies whose experiences shaped the review must remain at the heart of efforts to improve maternity care.
