A landmark review into Nottingham University Hospitals NHS Trust (NUH) has found that more than 520 mothers and babies suffered potentially avoidable harm or death due to poor care. The probe, led by senior midwife Donna Ockenden, examined cases from 2012 to 2025 and uncovered a systemic culture of denial and failures in oversight.
Key Findings of the Review
The review identified 94 stillborn babies, 62 babies who died shortly after birth, and 105 babies who suffered brain damage. Six pregnant women also died due to failures that 'may have or substantially impacted on the outcome'. Causes included oxygen starvation, mismanaged labour, hospital-acquired infections, and poor postnatal care.
Failures in Care and Oversight
Short-staffed maternity units at Nottingham City Hospital and Queen's Medical Centre routinely discouraged pregnant women from attending during labour, even when concerns like lack of foetal movement were raised. In some cases, this delay proved fatal. The report concluded that many oversight systems for maternity care in England 'are no longer fit for purpose', highlighting failures by the Nursing and Midwifery Council, Human Tissue Authority, and Care Quality Commission.
Personal Stories of Tragedy
Physiotherapist Sarah Hawkins and her husband, hospital consultant Jack, lost their first child, Harriet, in 2016. Despite Sarah's pleas, midwives refused to admit her until her sixth day of labour, when scans showed Harriet had died. The trust initially claimed infection caused the death. Sarah said: 'They killed my daughter, they covered up, they ruined our careers and they ruined our lives.'
Culture of Denial and Bullying
Ms Ockenden's team found leaders oversaw a 'culture of organisational denial', aware of serious issues since before 2010 but failing to act. Managers engaged in bullying, ignored staff concerns, and were sometimes rude and aggressive. The report noted maternal deaths are at a 20-year high.
Post-Mortem Failures
The review examined 17 babies and one adult who died, finding 'recurring examples of failure to protect the dignity of the deceased'. One early gestation baby was disposed of as clinical waste, another was placed in a mortuary space already occupied by an unrelated adult, and a third was kept in a domestic fridge in a bereavement room. On Monday, Nottinghamshire Police arrested two men in connection with mortuary practices.
Government Response and Calls for Inquiry
Health Secretary James Murray apologised in the House of Commons, saying the failures showed a 'level of disrespect and lack of humanity that, I'll be honest, left me aghast'. The government announced the rollout of 'Martha's Rule' to all maternity units, giving families 24/7 access to a second opinion. However, families are demanding a full statutory public inquiry with powers to compel evidence. Lead campaigner Dr. Hawkins expressed concerns about a separate national review led by Baroness Valerie Amos, calling it 'not independent' and 'commissioned by the same people who allowed Nottingham to happen'.
Apology and Ongoing Improvements
NUH trust chairman Nick Carver and chief executive Anthony May, both appointed in 2022, apologised unreservedly in an open letter, acknowledging improvements are needed. Ms Ockenden expressed gratitude to families who shared their experiences, hoping the report would 'drive real and lasting change to maternity services in England'.
