The Ockenden report into maternity services at Nottingham University Hospitals NHS trust (NUH) has revealed horrifying and systemic failures, with women routinely dismissed, gaslit, and ignored. The scale of suffering includes babies who died due to poor care, a woman told to labour at home for six days before surgery, a student doctor performing an emergency hysterectomy that accidentally removed a bladder, and a baby's remains disposed of as clinical waste.
Victims campaigned for years
Victims and survivors, including Sarah Hawkins and Gary Andrews, fought long and hard for this review. Hawkins described how they were made to feel like "mad grieving parents" after the death of their daughter Harriet. Nearly half of senior staff at NUH refused to speak to the review, according to the report.
Systemic failures and toxic culture
The report found that poor care was "deep-rooted" and "systemic," with a "toxic" workplace culture and widespread staff shortages. Women consistently reported feeling dismissed, disempowered, or blamed when they expressed anxiety or reported critical symptoms such as reduced foetal movements, severe pain, hypertension, and postnatal deterioration. Their concerns were minimised as maternal anxiety.
One clinician told Gary Andrews, father of Wynter who died of oxygen deprivation, "If we listened to every mother's concerns, we'd be overrun." Andrews responded: "If you'd listened to every mother's concerns, there would be hundreds of mothers, babies, still alive."
Medical misogyny and disparities
The report highlights deeply embedded medical misogyny, often combined with racism and classism. Failures to listen were even more pronounced for women from Black, Asian, and other ethnic backgrounds, as well as teenage mothers and those from deprived backgrounds. This issue extends beyond Nottingham across the NHS.
Many women have similar stories: first-time mothers told to take paracetamol and have a hot bath, women denied pain relief, or laughed at by midwives. Acute feelings of powerlessness during labour often lead to birth trauma.
Need for change
The extension of Martha's rule—the right to a second opinion—to maternity units is a welcome change but still relies on patients' ability to advocate for themselves. A well-funded, humane maternity system with skilled, valued staff and accountable management is essential. The government owes it to victims and all pregnant women to ensure this never happens again.
