An inquiry into NHS England’s biggest ever maternity scandal has revealed that more than 500 mothers and babies came to harm or died because of inadequate care at the Nottingham Trust, reports The Guardian.
A total of 444 women and 76 newborn babies suffered “potentially avoidable” outcomes because of substandard treatment over 13 years from Nottingham University Hospitals NHS trust (NUH), according to the report led by childbirth expert Donna Ockenden.
The 401-page document paints a horrendous picture of maternity care at its two hospitals – Queen’s Medical Centre and Nottingham City Hospital – where “multiple” women experienced dangerously poor and sometimes “cruel” care, understaffing was routine, lessons from patient safety incidents were not learned, and bullying by “intimidating cliques” of staff was rife.
Ockenden and her team of maternity experts who undertook the three-year inquiry investigated the deaths of 27 mothers between 2006 and 2024 and “identified failures in care that may have or substantially” had an impact on the outcome in six deaths.
Staff not listening to women or acting promptly on concerns they raised was one of the common failures involved in maternal deaths, they found, as well as delays in women having scans.
The review was ordered in 2023 after families warned that maternity care at NUH care was unsafe. It also examined cases in which babies died as a result of being oxygen-deprived during birth or picking up a hospital-acquired infection, or because midwives and doctors did not manage the mother’s labour properly or provided poor postnatal care.
Thirty-one of the detailed examinations of the deaths of newborn babies found that they had received inadequate care and that, if they had been handled differently, they would probably have avoided coming to harm.
The report exposes a host of recurring failings in clinical care that put mothers and babies at risk and in some cases had catastrophic consequences. They included repeated failures to monitor babies properly during labour, misinterpretation of CTG trace-reading of the baby’s health while still in utero, not recognising when babies were in distress, and midwives not escalating worrying cases urgently to doctors to make rapid decisions on the care and treatment needed.
“In a number of cases these failures contributed to severe neonatal injury, stillbirth and neonatal death,” Ockenden’s report says.
About 2 500 families and 850 current or former NUH staff gave evidence to the review team, which examined events from 2012 to 2025. It also found that:
• A “bullying and toxic culture” persisted at NUH over many years and impeded moves to improve care.
• Maternity service managers and the trust’s senior leaders were repeatedly warned about a host of serious problems in the maternity units at both hospitals but did not take effective action.
• Maternity staff displayed “a culture of not admitting women who were seeking admission in labour”, despite the risks this posed to them and their babies.
• Both maternity units were consistently seriously short-staffed and could not cope with the number of births and complexity of cases they had to handle.
• One baby girl who died early in gestation was “inadvertently disposed of as clinical waste by laboratory staff after her post-mortem examination”, compounding her parents’ distress.
In behaviour that Ockenden said was sometimes racist, “cruel” and lacking compassion, staff could be dismissive of women’s concerns. One said she was told: “Is this your first baby? Take some paracetamol and have a hot bath.’”
The Nottingham Maternity Families group, which represents about 600 harmed and bereaved families, renewed its plea to the Prime Minister to establish a statutory public inquiry to investigate maternity failings across England.
The families described as “appalling” the fact that many NUH senior managers chose not to give evidence to the inquiry, and suggested they be sacked.
“You have demonstrated that maternity safety doesn’t matter to you, but self-preservation does. Your failure to engage constructively and with candour in this review process is further proof you are unfit to keep mothers and babies safe.
“Questions need to be asked by senior leaders and regulators whether you are fit to work in the NHS,” they said in a statement.
Health Secretary James Murray has responded by announcing that Martha’s rule – which gives patients the right to an independent second opinion of their care by a separate clinical team – would be implemented at every maternity unit in England, as suggested by Ockenden.
In future, current or past NHS staff who refuse to give evidence to maternity inquiries will also have to do so or risk being jailed for up to two years, to try to break the ingrained “culture of silence” that often accompanies care failings and medical negligence.
While the report is a scathing indictment of poor maternity care over many years at NUH, it follows previous reports into similar failures at three other NHS trusts in England in recent years, with ministers and NHS leaders admitting that multiple recommendations from those and other inquiries to improve care had not been implemented and that major problems persist.
See more from MedicalBrief archives:
Ockenden Report into ‘one of the biggest scandals in NHS history’
Final report on UK maternity scandal that led to 100s of brain-damaged or stillborn babies