A damning independent report into maternity care at Nottingham University Hospitals NHS Trust (NUH) has found that more than 500 mothers and babies died or suffered harm due to inadequate care over a 13-year period. The inquiry, led by former midwife Donna Ockenden, identified 444 women and 76 newborn babies who experienced “potentially avoidable” outcomes because of substandard treatment between 2012 and 2025.
Report Details Widespread Failures
The 401-page report paints a stark picture of a “bullying and toxic culture” at NUH’s two hospitals—Queen’s Medical Centre and Nottingham City Hospital—where staff were routinely dismissive of women’s concerns, understaffing was endemic, and lessons from safety incidents were not learned. Ockenden’s team investigated 27 maternal deaths and found that failures in care may have substantially impacted outcomes in six cases. Common failures included staff not listening to women, delays in scans, and a “cruel” attitude.
The review examined cases where babies died from oxygen deprivation during birth, hospital-acquired infections, or poor management of labour and postnatal care. In 31 detailed examinations of newborn deaths, inadequate care was identified, and different handling would likely have prevented harm.
Key Findings from the Inquiry
About 2,500 families and 850 current or former staff gave evidence. The report found that maternity service managers and senior leaders were repeatedly warned about serious problems but failed to take effective action. Staff displayed a “culture of not admitting women seeking admission in labour,” despite risks. Both units were consistently short-staffed and unable to cope with birth numbers and case complexity. In one distressing incident, a baby girl who died early in gestation was “inadvertently disposed of as clinical waste” after a postmortem, compounding her parents’ grief.
Families reported horrendous experiences, including denial of pain relief or being told to “pull yourself together.” One woman was advised: “Is this your first baby? Take some paracetamol and have a hot bath.”
Calls for Statutory Public Inquiry
The Nottingham Maternity Families group, representing about 600 harmed and bereaved families, renewed its plea for a statutory public inquiry into maternity failings across England. Health Secretary James Murray said he was “not going to take it off the table” and focused on Ockenden’s report to pursue accountability and change. Families described as “appalling” the fact that many senior NUH managers chose not to give evidence, suggesting they should be sacked.
Ockenden’s report highlighted that Jack and Sarah Hawkins experienced “suppression of information” by NUH and regulatory bodies when seeking answers about their daughter Harriet’s stillbirth in 2016.
Government Response and Wider Context
Murray announced that Martha’s rule—giving patients the right to an independent second opinion—will be implemented at every maternity unit in England, as Ockenden suggested. Future NHS staff who refuse to give evidence to maternity inquiries could face up to two years in jail to break the “culture of silence.” Murray vowed to “deliver lasting change” in NHS maternity services.
Kim Thomas, CEO of the Birth Trauma Association, said the report showed that “when complaints were made, the trust’s instinct was to cover up, rather than investigate, failings,” adding that Nottingham is not unique. Kath Abrahams, CEO of Tommy’s, called the report “truly harrowing” and condemned the racist and unkind behavior and deliberate efforts to avoid scrutiny.
The report follows similar scandals at Morecambe Bay, East Kent, and Shrewsbury and Telford NHS trusts. Lady Amos is due to publish a government-commissioned inquiry into maternity and neonatal care next week, aiming to ensure safe, high-quality care for all.
