The Ockenden report into maternity services at Nottingham University Hospitals NHS Trust says local and national action is now needed to improve the safety of maternity care.
The independent review, published today, sets out findings, conclusions and essential actions following the examination of maternity and neonatal care at NUH between 2012 and 2025.
Donna Ockenden, chair of the Independent Maternity Review, said her team had identified clear evidence forming the basis for both Local Actions for Learning at NUH and England-wide Immediate and Essential Actions. She said these should be swiftly implemented at the Trust and across the wider perinatal system in England.
The report says the overarching principle is that women, families and staff must be able to seek urgent additional clinical review by using Martha’s Rule. It also says women must be at the centre of clinical communication and informed decision-making, and that national assessment and escalation processes across perinatal care should be standardised.
Martha’s Rule is referred to in the report as part of the need for urgent additional clinical review when concerns are raised. In practical terms, the report’s findings point to the importance of concerns from women, families and staff being heard and acted on quickly, particularly when there are signs of deterioration or disagreement over clinical judgement.
The review found repeated problems in listening, communication, escalation and learning. Families described care being shaped by whether they felt listened to and believed, whether information was consistent, and whether they were involved in decision-making. Women described poor communication, delayed or missing observations, failures in escalation and loss of autonomy.
The report says current maternity grading systems focus too heavily on outcomes rather than quality-of-care processes, including listening, early recognition, escalation and teamwork. It says a more efficient approach is needed, recognising not only where care has fallen short, but also where staff have delivered excellent care in difficult circumstances and prevented harm.
The report says the development of Immediate and Essential Actions, and a new assessment tool being developed by the Ockenden team, aims to begin a cultural shift within maternity services. It says success will require engagement from all maternity providers, government support led by the Maternity and Neonatal Taskforce, and continued inclusion of diverse and representative service-user perspectives.
For NUH, the report says measurable progress has been made in leadership, workforce development, culture, training and learning. It says the most recent CQC inspection published in 2026 recognised areas of improvement. However, it says further work is needed to embed changes and ensure they are sustained.
The review says since 2021 NUH has implemented deliberate measures to strengthen visible clinical leadership in maternity services. Work to change and improve culture has included regular reviews of Freedom to Speak Up reports, Datix insights, staff surveys and quarterly Listening Forums led by the Director of Midwifery.
The report also refers to improvements in specific areas. It says triage had been a weak link over the review period, with examples of poor telephone risk assessment, missing documentation and a culture of discouraging women from attending in person, but says there is evidence this has significantly improved since 2022.
In fetal monitoring, the review found examples of incorrect interpretation, poor documentation, poor escalation and poor training. However, it also found evidence of notable improvement in fetal monitoring practice following the introduction of a dedicated fetal monitoring lead midwife in April 2021.
The review says neonatal care was generally in line with national expectations, with many examples of good and exceptional practice. It notes that significant cot capacity pressures and short-staffing had affected workload and the quality and safety of neonatal services until December 2024, when a new larger unit opened.
The report’s findings also point to areas where practical change is needed for families after harm has occurred. It identifies recurring failures in accountability, including incomplete explanations, explanations inconsistent with clinical records, delayed or missing debrief appointments, and written communication lacking compassion or clarity.
The report says answers, accountability and properly resourced psychological support are essential when the loss of, or serious harm to, a baby or mother is considered preventable. It says all families included in the review have been offered support from a Family Psychological Support Service.
The report also identifies wider issues around inequalities. It says Nottingham is one of England’s most demographically diverse and socio-economically deprived cities. Global majority voices were under-represented among review families who felt able to share their stories, but the accounts gathered raised themes including communication failures, not being believed, cultural misunderstanding, fear, mistrust, power imbalance and systemic barriers.
The review says these factors affected women’s ability to escalate concerns, seek help and engage fully with care. It also says fathers and partners should be included in family-centred care, particularly during labour, delivery and the postnatal period.
Donna Ockenden said safe, compassionate and equitable perinatal care was still achievable in Nottingham and across England, but only if there was an unwavering commitment to accountability, learning, transparency and kindness at every level of the system.
