A damning three-year review has uncovered the biggest childbirth scandal in NHS history, with 520 mothers and babies in Nottingham suffering 'potentially avoidable' harm or death. Health Secretary James Murray described the failings as 'horrific' and 'chilling,' and families are now calling for a statutory public inquiry into maternity care across England.
Report findings: 444 women and 76 babies harmed
The review, led by maternity safety expert Donna Ockenden, examined maternity services at Nottingham University Hospitals NHS Trust (NUH) between 2012 and 2025. It found that 444 women and 76 newborn babies experienced 'potentially avoidable' outcomes. Murray said families suffered 'dangerously and tragically deficient care at almost every turn' and that 'the NHS failed them catastrophically.'
Ockenden's 401-page report painted a stark picture of neglect, incompetence, racism, discrimination, contempt, and harassment. She found that 'multiple' women experienced dangerously poor and sometimes 'cruel' care, understaffing was routine, lessons from safety incidents were not learned, and bullying by 'intimidating cliques' of staff was rife.
Families demand public inquiry
The Nottingham Maternity Families group, representing about 600 harmed and bereaved families, has asked Prime Minister Keir Starmer to establish a statutory public inquiry to investigate failings in maternity and neonatal care across the entire NHS. 'Because safe care can only be consistently delivered when the full truth is known,' they stated.
Murray said the government is considering the request but noted that not all families support a public inquiry. 'Some want a public inquiry, others take a different view, but what unites all of the families I spoke to is a desire for accountability and a desire to see change,' he said.
Maternal deaths and newborn harm
Ockenden's team investigated the deaths of 27 mothers between 2006 and 2024, identifying failures in care that 'may have or substantially impacted on the outcome in six deaths.' Common failures included staff not listening to women or acting promptly on concerns, and delays in women having scans.
Detailed examinations of 31 newborn deaths concluded that they had received inadequate care and that, if handled differently, they would probably have avoided harm. The report highlighted repeated failures to monitor babies properly during labour, misinterpretation of CTG trace-readings, not recognising when babies were in distress, and midwives not escalating urgent cases to doctors.
'In a number of cases these failures contributed to severe neonatal injury, stillbirth and neonatal death,' the report says.
Bullying culture and staff refusal to cooperate
The review gathered evidence from 2,536 families and 838 current or former NUH staff. It found a 'bullying and toxic culture' persisted at NUH for many years, with managers and senior leaders repeatedly warned about serious problems but failing to take effective action. Staff displayed 'a culture of not admitting women who were seeking admission in labour,' despite risks.
Both maternity units were consistently seriously short-staffed and could not cope with the number of births and complexity of cases. In one horrifying incident, a baby girl who died early in gestation was 'inadvertently disposed of as clinical waste by laboratory staff after her postmortem examination,' compounding her parents' distress.
Almost half of the 66 current and former NUH executives asked to engage with the inquiry did not do so, despite multiple requests. Among leaders in NHS clinical commissioning groups and integrated care boards, only four of 14 contacted participated. Ockenden described the trust as dysfunctional, badly run, and determined to hide the dangerous truth.
Government response and Martha's rule
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. Additionally, current or past NHS staff who refuse to give evidence to maternity inquiries may face up to two years in jail to break the 'culture of silence.'
NUH Chief Executive Anthony May and Chair Nick Carver apologised unreservedly, saying: 'We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services.'
Kim Thomas, CEO of the Birth Trauma Association, said the report showed how 'when complaints were made, the trust's instinct was to cover up, rather than investigate, failings.' She added: 'Sadly, we believe that Nottingham is not unique.'
