The long awaited Ockenden Review setting out its findings into maternity and neonatal care at Nottingham University Hospitals NHS Trust has been published today. A copy of the report can be found here.
The investigation, led by Donna Ockenden, examined the care and treatment provided to 2,511 families at City Hospital and the Queen’s Medical Centre, in Nottingham. A further 556 families also came forward to share their experiences, and of these 533 families consented to having their stories shared, contributing to a broader understanding of the issues identified in the report. Their voices must become the catalyst for urgent, national change.
Background to the review
The Ockenden Review was commissioned following serious concerns raised by numerous families about the safety and quality of maternity and neonatal care at Nottingham University Hospitals NHS Trust.
It represents one of the most significant investigations into maternity services in England, reviewing approximately 2,500 cases spanning April 2012 to May 2025.
The review has been shaped by the experiences of families affected by serious harm caused to them or their babies, tragically resulting in their deaths on many occasions. The families have campaigned extensively for accountability and change, and it is hoped the findings from the review will take a vital step in achieving this.
Key findings
The report identifies a number of serious and longstanding concerns relating to maternity care, describing deeply embedded systemic failures and a “toxic” culture within the service.
These include:
- failures in clinical care, including mismanagement of labour and delays in intervention;
- delays in escalation and failures to act on emerging risks (as experienced by our own client);
- poor communication with families, with concerns not being listened to or acted upon;
- staffing pressures, cultural issues and a reluctance among staff to speak up; and
- failures in leadership, governance and organisational oversight.
The review found that more than 500 mothers and babies died or suffered harm unnecessarily, with at least 160 deaths considered potentially avoidable had appropriate care been provided.
In a number of the cases reviewed, different or better care may have changed the outcome including:
- 21% of cases involving maternal deaths;
- 26% of cases involving major obstetric haemorrhage;
- 36% of cases involving unplanned admission to intensive care;
- 20% of cases resulting in stillbirth; and
- 50% of cases resulting in hypoxic brain injury.
Whilst there was a significant amount of poor practice and failings in care identified, the review does also highlight examples of good practice, including:
- improvements made by the Trust since the review began, including increased focus on safety and oversight;
- commitment from many frontline staff to provide compassionate care despite challenging conditions; and
- those that fought to raise concerns being recognised as deserving reward and respect.
Impact on families
The report details the devastating impact that failures in care have had on families, many of whom have faced life changing consequences including bereavement, serious injury and long term trauma.
In many cases, the report found that the impact of clinical failings was compounded by the way in which concerns and complaints were handled by the Trust, having a further impact on family’s experiences.
Families described not being listened to, being dismissed when raising concerns, and facing significant barriers when seeking answers after a poor outcome. Further, express wishes of parents were not followed, with a baby being disposed of as “clinical waste” and another stillborn baby being placed in the same mortuary space as a deceased adult.
There was great emphasis placed by Donna Ockenden on the importance of listening to families and ensuring their voices remain central to improvements across maternity services. We must have a system where compassion is integrated into every aspect of a person’s care, including after their death.
The review also found that women who were from minority backgrounds and from areas of disadvantage across Nottingham were at the most risk of harm. Donna Ockenden has said: “Safe equitable maternity care is not a luxury, it is a fundamental obligation of a civilised health service.” This is a real concern for families placing their care in maternity services across the UK, and sadly the findings of the report will likely increase concerns.
The review has highlighted that many families did not understand the impact of the failings in the care they suffered, until they instructed lawyers who fully investigated their care. Donna Ockenden highlights that many families remain in this position.
Recommendations
The report identifies eight key areas for immediate improvement across maternity services:
- Listening to women and families – ensuring concerns are heard, respected, and acted upon, with families fully involved in care and investigations.
- Workforce planning and safe staffing – developing a nationally agreed approach to staffing levels to ensure services are safe and sustainable.
- Education, training and clinical competency – strengthening mandatory training and ensuring staff maintain the skills required to deliver safe care.
- Early identification and management of risk – improving processes to recognise and respond to risks during pregnancy, labour and postnatal care.
- Incident investigation and learning – ensuring serious incidents are properly investigated, with learning shared and embedded across services.
- Accountability and governance systems – strengthening leadership oversight and ensuring clear accountability for patient safety.
- Organisational culture and staff support – creating compassionate, inclusive and psychologically safe working environments where staff can speak up.
- Care following death and bereavement support – improving the standard of care and support provided to families following the death of a baby or mother.
These recommendations are expected to inform both local changes at the Trust and wider national maternity policy. This must be a moment of collective action, sustained improvement, and improved competence.
Donna Ockenden has said there is a clear principle that underlines this all; when women, families or staff have concerns about maternity care being provided, they must be able to seek an urgent second opinion under the principle of Martha’s Rule.
Response from Nottingham University Hospitals NHS Trust
Nottingham University Hospitals NHS Trust has acknowledged the findings and outlined the steps it will take to address the concerns raised, including:
- continuing its maternity improvement programme;
- strengthening leadership and governance structures; and
- focusing on rebuilding trust with families.
NHS England and the Department of Health are also expected to outline further national actions in response to the report, recognising the wider implications for maternity services across the country.
What happens next
The publication of the Ockenden Review marks an important step in understanding what went wrong in Nottingham and how maternity services must improve.
Implementation of the recommendations will be closely scrutinised, with the expectation that lessons will be learned and applied across maternity services nationwide.
For affected families, the report represents both recognition of their experiences and a continued call for accountability.
However, this was not an isolated incident. Numerous investigations into maternity services have already happened such as in Shrewsbury and Telford Hospitals NHS Trust and East Kent and further reviews, also led by Donna Ockenden, have been announced at University Hospitals Sussex NHS Foundations Trust and Leeds Teaching Hospitals NHS Trust. This in part, is why the government announced the National Maternity and Neonatal Investigations review, currently being led by Baroness Amos. The initial findings were published in December, and sadly many of the issues found mirror those in Nottingham. Therefore, it is vital that real action is taken to avoid a continuing cycle of devastation for families.
How we can help
If you are concerned about the care you or your baby received, we are here to support you with our specialist team. Our team has extensive experience supporting families following birth injuries and maternity care failings. We are here to listen, provide guidance, and help you understand your options.
We offer all initial discussions free of charge and with no obligation to proceed. To talk to one of our experts, call us on 0800 044 8488 or fill in our contact form so we can call you back at a time convenient to you.
