A damning review has concluded that more than 500 mothers and babies suffered potentially avoidable harm or death at Nottingham University Hospitals NHS Trust (NUH), citing 'deeply embedded systemic failures' and a 'toxic' culture. The report, led by senior midwife Donna Ockenden, found that trust bosses were aware of serious issues in the maternity department for years but failed to act, leading to preventable deaths.
Key findings of the review
Overall, 520 mothers and babies experienced potentially avoidable harm or death, including 94 stillbirths. There were 62 neonatal deaths, with babies dying from oxygen starvation, mismanaged labour, hospital-acquired infections, and poor postnatal care. Experts found that failures in care 'may have or substantially impacted on the outcome in six deaths' of women. Among the cases, baby Harriet Hawkins died 'avoidably' in 2016, Wynter Andrews died in 2019 after significant failures, and Ladybird's parents were wrongly told to terminate a healthy pregnancy.
Systemic failures and missed opportunities
The review identified that women and families were consistently not listened to, leading to missed opportunities to prevent harm. There were failures to recognise and escalate deterioration in babies' and mothers' health. Assessors found 'multiple examples where failures in neonatal care may have contributed to long-term brain injury and adverse neurodevelopmental outcomes'. Leadership instability was a 'major contributing factor', with sustained turnover in senior maternity positions between 2017 and 2021.
Toxic culture and bullying
The report described a 'bullying and toxic culture' at the trust, with staff forming intimidating cliques that were not challenged. Staff reported 'a culture of organisational denial' where poor outcomes were dismissed as 'known complications'. There were multiple examples of poor telephone risk assessment, missing documentation, and a 'culture of discouraging women to attend in-person'. Some women in labour faced delays in examination, and staff were reluctant to escalate concerns due to professional cultures.
Failures in care and governance
From at least 2012, there was poor governance within maternity, including serious incidents not being investigated and a failure to learn from mistakes. Staff shortages and operational pressures led to staff working 'beyond safe capacity'. In postnatal care, mothers with high blood pressure or deterioration were not adequately assessed, and some patients received phone calls instead of in-person visits. The review also found inappropriate use of the drug oxytocin to induce labour and delays in recognising postpartum haemorrhage.
Impact on families and staff
More than 2,500 families and over 800 staff contributed to the largest maternity inquiry in NHS history. NUH has already paid millions in compensation and fines. The review examined 17 babies and one adult who died, finding failures to protect the dignity of the deceased, including an early gestation baby disposed as clinical waste. Nottinghamshire Police arrested two men in connection with mortuary service practices.
Calls for change
Donna Ockenden said: 'We owe it to every mother, every baby and every family whose terrible experiences are recorded here that they are never repeated.' She added that the 'culture of compounding of harm needs to stop'. Clea Harmer, chief executive of Stillbirth and Neonatal Death Charity (Sands), said: 'Reading Donna Ockenden's report is absolutely heartbreaking... These personal testimonies reveal trauma and pain that was compounded by families not being listened to or believed.' Health Secretary James Murray pledged to 'deliver lasting change', and the Department of Health and Social Care announced that Martha's Rule will be extended to all maternity settings in England. NUH chair Nick Carver and chief executive Anthony May apologised 'unreservedly' in an open letter.
