An independent review of maternity services at Nottingham University Hospitals NHS Trust has unveiled a harrowing account of systemic failures that have adversely affected hundreds of mothers and babies. The extensive investigation, led by senior midwife Dr. Donna Ockenden, spanned three years and gathered insights from over 2,500 families along with input from more than 800 staff members associated with the Trust. The findings, released on June 24, have ignited a call for a nationwide public inquiry into maternity care across the UK.
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The staggering report highlighted over 500 cases of significant harm or death, primarily due to what were described as “potentially avoidable” circumstances. It detailed 444 maternity incidents and 76 neonatal cases that raised serious concerns about the care provided. These issues reportedly date back to 2012 and span until May 2025. In a press briefing, Ockenden remarked, “This is a report about how a system failed, and what it costs when it fails. It costs lives, futures and families, everything.”
The 400-page document paints a picture of a toxic culture within the Trust’s maternity services. Numerous mothers described experiences of being doubted and dismissed during labour, often denied adequate pain relief. One woman recounted a particularly distressing incident during which staff reportedly advised her to “pull yourself together” while she was in pain. Another mother expressed anguish at being told to simply take paracetamol and have a hot bath during a critical moment.
The report further highlighted case studies illustrating the extent of neglect. It referenced instances where parental concerns about their babies’ health were repeatedly ignored, leading to tragic outcomes including stillbirths. One case detailed a mother who was not provided the necessary one-to-one care during her high-risk labour, resulting in the loss of her child. In another deeply disturbing account, a baby was disposed of like clinical waste after a post-mortem examination, causing profound grief for her parents due to the complete loss of dignity for their child.
Staff feedback corroborated the families’ experiences, revealing a prevalent culture of bullying within the maternity wards. Over 40% of the staff surveyed reported having either witnessed or faced bullying from managers and colleagues. The atmosphere reportedly created an environment where healthcare workers felt powerless to speak out against malpractice. Incidents of poor management, combined with an intimidating workplace culture, allowed a “small minority of powerful leaders” to dominate and propagate harmful practices.
Moreover, documentation relating to two maternal deaths was destroyed by the Trust, rendering any investigation impossible. Many former staff members claimed they left their roles due to the perception that clinical incidents were routinely overlooked or concealed. This culture of silence highlights the dire need for transparency and accountability within the maternity services structure.
In light of the findings, the Trust’s leadership issued an open letter to the local community, offering an unequivocal apology to those who have suffered as a result of inadequate care. NUH chairman Nick Carver and chief executive Anthony May acknowledged the Trust’s failings, stating, “We failed you, and on behalf of Nottingham University Hospitals Trust, we accept responsibility for our failings.” The letter included a commitment to meaningful reform and reflection on the report’s findings.
Health Secretary James Murray expressed his horror at the report’s revelations, describing the experiences shared by families as “chilling” and “horrific.” He acknowledged the widespread trauma endured not only by those present but also by countless families across the nation who may have experienced similar failures. In response to the report, he confirmed that the government would take action, announcing that Martha’s Rule — a patient safety initiative that allows individuals to request rapid reviews of their care — will be extended across all maternity units in England.
The families impacted by the review are urging a statutory public inquiry to comprehensively assess maternity services across the entire country. Health Secretary Murray remarked that “no options are off the table,” indicating a readiness to consider wider systemic evaluations if deemed necessary.
This independent review represents a critical juncture for maternity services in the UK, underscoring the urgent necessity for change within the Nottingham University Hospitals Trust and potentially across the entire National Health Service. The report serves not only as an exposé of past failures but also as a call to action for improved standards of care, accountability, and support for mothers and their families. The sorrow and pain endured by so many cannot be overlooked, and it is imperative that steps are taken to ensure no one else suffers similar fates in the future.