The independent Ockenden review into maternity services at Nottingham University Hospitals NHS Trust has identified more than 1,500 individual failures in care, including avoidable deaths and brain injuries, according to a report published on Thursday. The review, led by senior midwife Donna Ockenden, examined cases from 2012 to 2020 and found systemic issues that harmed hundreds of families.
Key Findings of the Review
The review uncovered 1,586 separate failures across 595 maternity cases. These included delays in treatment, poor communication, and a lack of senior staff oversight. In 32 cases, the care was so poor that it contributed directly to the death or severe brain injury of a baby. The report highlighted that many of these failures were preventable and reflected a culture of denial within the trust.
According to the review, the trust failed to learn from previous incidents and did not implement recommendations from earlier inquiries. Staff shortages and high turnover were cited as contributing factors, with midwives and doctors often working under extreme pressure.
Impact on Families
The review heard harrowing testimony from families who experienced traumatic births and poor postnatal care. One mother described being told her baby was fine when in fact he was suffering from oxygen deprivation, leading to long-term disability. Another family recounted how their daughter died due to a missed diagnosis of sepsis.
Donna Ockenden said: "We have seen repeated patterns of failure, where the same mistakes are made over and over again. The trust has let down families who placed their trust in them. This must stop."
Trust Response and Reforms
Nottingham University Hospitals NHS Trust has accepted the findings and issued an apology. Chief executive Anthony May said: "We are deeply sorry for the pain and suffering caused to families. We are committed to making the necessary changes to ensure safe and compassionate care." The trust has already implemented some reforms, including hiring additional midwives and improving training, but the review indicates that much more needs to be done.
The government has pledged to support the trust in implementing the recommendations, with Health Secretary Wes Streeting stating: "This report is a damning indictment of failures that should never have happened. We will ensure that lessons are learned and that maternity services are transformed." The review calls for a national investigation into maternity safety and for mandatory reporting of serious incidents.
