An independent review into maternity services at Nottingham University Hospitals (NUH) NHS Trust has found that more than 500 mothers and babies experienced potentially avoidable deaths or serious harm over more than a decade due to failures in clinical care, poor leadership, and a deeply entrenched toxic workplace culture.
The review, led by senior midwife Donna Ockenden, examined maternity care provided at Queen's Medical Centre and Nottingham City Hospital. Published on June 24, 2026, the 401-page report represents the largest maternity review in NHS history.
The investigation was commissioned in 2023 following years of concerns raised by bereaved families over the safety of maternity services at the trust. Over the course of three years, the review team heard evidence from more than 2,500 families and over 850 current and former NUH staff members, with more than 160 multidisciplinary reviewers contributing to the investigation.
The report identified 444 maternity cases and 76 neonatal cases with "significant" or "major" concerns where outcomes were considered potentially avoidable. These cases spanned from 2012 to May 2025.
"This is a report about how a system failed, and what it costs when it fails," Ockenden said during a press briefing. "It costs lives, futures and families, everything."
The review describes "longstanding and deeply embedded systemic failures" throughout NUH's maternity services. Investigators found repeated shortcomings in fetal monitoring, delays in responding to maternal concerns, inadequate clinical decision-making, and failures to escalate high-risk cases promptly.
Recurring problems included misinterpretation of cardiotocography (CTG) traces, delayed recognition of fetal distress during labour, delays in performing scans, poor labour management, inadequate postnatal care, and insufficient communication between midwives and obstetric teams.
The review concluded that these failures contributed to severe neonatal injuries, stillbirths, and neonatal deaths.
Ockenden's team also reviewed 27 maternal deaths occurring between 2006 and 2024 and found lapses in care that may have or substantially contributed to the outcome in six deaths.
Staff repeatedly failed to listen to women or respond promptly to concerns they raised, with delays in assessment and treatment emerging as common themes throughout the review.
Beyond clinical shortcomings, the report highlights a workplace culture marked by bullying, intimidation, aggression, and fear.
More than 40% of staff who participated in the review reported either experiencing or witnessing bullying by managers or colleagues. Staff described an environment where speaking up about safety concerns was discouraged and where a "small minority of powerful leaders" exerted disproportionate influence over maternity services.
Managers were described as dismissive, punitive, and unapproachable, while several staff members said they left the trust because serious clinical incidents were "brushed under the carpet."
The report concludes that a persistent bullying culture prevented learning from patient safety incidents and repeatedly obstructed efforts to improve maternity care.
The review also found that fear of speaking up extended beyond frontline staff, with concerns that patient safety incidents were sometimes underreported or insufficiently investigated, limiting opportunities to improve care.
Investigators also found that maternity units remained chronically understaffed for many years, making it difficult to safely manage the volume and complexity of births.
Many women told reviewers they felt ignored, dismissed, or disbelieved while seeking medical care during pregnancy and labour.
Some reported being denied pain relief or receiving inadequate pain management despite repeated requests.
"It felt brutal … traumatic … They were screaming at me: 'You need to pull yourself together,' " one woman recalled in testimony included in the report.
Another woman said staff told her, "Is this your first baby? Take some paracetamol and have a hot bath."
One mother reported, "We had nobody come and visit us for at least 3 hours… Nobody came to check on me. Nobody came to check on baby."
Some families also said they felt blamed for poor outcomes or were given incomplete or misleading explanations following serious incidents, making it more difficult to understand what had happened to their babies.
The review also found evidence of a culture in which women seeking admission during labour were sometimes discouraged or refused admission despite potential risks to themselves and their babies.
The report documents numerous cases illustrating the consequences of failures in maternity care.
The review describes a 2019 incident in which "one very early gestation baby was inadvertently disposed as clinical waste by laboratory staff after her post-mortem examination, resulting in a complete loss of dignity for the baby and significant distress to her parents."
In one case, a baby died at home after the parents' concerns were repeatedly dismissed by midwives.
Another baby died after the mother did not receive the one-to-one care and medical attention required for her high-risk labour.
Several families told investigators that their babies had been referred to as "specimens" by members of staff.
In another case, a couple were reportedly advised to terminate a pregnancy before later investigations confirmed that their daughter was healthy.
The report further revealed that medical records relating to two maternal deaths had been destroyed by the trust, preventing investigators from fully examining those cases.
Following publication of the report, the Nottingham Maternity Families group, representing approximately 600 bereaved and affected families, renewed calls for a statutory public inquiry into maternity care across England.
Families also criticized senior NUH leaders who declined to participate in the review, stating that their actions demonstrated a lack of accountability.
The report recounts the experience of Jack and Sarah Hawkins, whose daughter Harriet was stillborn at Nottingham City Hospital in April 2016. Investigators found they experienced suppression of information by NUH and several regulatory bodies while seeking answers about their daughter's death.
Health Secretary James Murray described the findings as "chilling" and "horrific."
"I felt numb after hearing the depth of their pain," Murray said during a press conference. "I felt even more numb when I considered how many families not in the room went through such trauma too, and the forgotten children who survived but lived with the consequences of failings in maternity care every day."
Murray said the government would act on the report's recommendations and announced that Martha's Rule, which allows patients and their families to request an urgent independent review if they believe a patient's condition is deteriorating, would be extended to every maternity unit in England.
He also said former and current NHS staff who refuse to cooperate with future maternity inquiries could face up to two years' imprisonment, aiming to address what the government described as a longstanding culture of silence.
Responding to calls for a statutory public inquiry, Murray said "no options are off the table."
In an open letter to the people of Nottinghamshire, NUH Chairman Nick Carver and Chief Executive Anthony May apologized to affected families.
"We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services. We failed you, and on behalf of Nottingham University Hospitals Trust, we accept responsibility for our failings," they wrote.
The trust added: "We recognise that trust is earned through actions, not words. We know, also, that families and the wider public will judge us not by what we say today, but by what we do next."
Acknowledging that further improvements remain necessary, the trust stated: "The review makes clear that while improvements have been made, there is still more to do. We will take time to reflect on the report with humility, honesty and determination."
The review contains 81 Essential Actions aimed at improving maternity safety, many of which NHS England and the government have pledged to implement.
Reference:
1. Ockenden, Donna. Findings, Conclusions and Essential Actions from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust. Independent Review of Maternity Services, June 24, 2026. Accessed June 27, 2026. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2026/06/ockenden-report-review-of-maternity-services-nottingham-university-hospitals-nhs-trust-web-accessible.pdf
(Rh/ARC/MSM)