Donna Ockenden Review Finds Nottingham University Hospitals NHS Trust Systemic Failures Killed Mothers And Babies

A landmark maternity review led by senior midwife Donna Ockenden found that more than 500 mothers and babies suffered avoidable harm or died due to “deeply embedded” systemic failures at Nottingham University Hospitals (NUH) NHS Trust.

“- Published More than 500 mothers and babies suffered avoidable harm or died due to failings at a "toxic" hospital trust, a landmark maternity review has found”

BBC

The BBC reported that experts on the review concluded there were “potentially avoidable” outcomes relating to 444 maternity cases examined up to May 2025, alongside 76 neonatal cases.

BBC

The Guardian said the review found failures in maternity and neonatal care were “systemic, deep-rooted and sustained over many years,” with repeated failures to accurately report, grade and investigate serious occurrences.

The Independent reported that the inquiry uncovered more than 500 cases of potentially avoidable harm, including care of mothers and babies in 94 stillbirths and 62 neonatal deaths.

The review also described a “persistent failure to listen to and believe mothers and fathers,” and the BBC said different care may have altered the outcome for 260 babies who died or were harmed.

The Guardian reported that women and families were consistently ignored when concerns were raised, with one woman described as being “sneered at for asking for pain relief,” and another told: “If you don’t like it, you should have gone somewhere else.”

In the same review, the BBC said Ockenden highlighted a “persistent failure to listen to and believe mothers and fathers” alongside a failure to investigate and therefore learn from mistakes.

Healthcare Management Magazine

The Independent quoted Ockenden saying systemic failings at the “toxic” Nottingham University Hospitals NHS Trust were “hauntingly consistent” for more than 10 years, despite leaders being aware of serious issues.

The Independent also described a “quest” for vaginal births, saying intervention was avoided and sometimes led to “tragic outcomes,” while it reported that the trust’s mortuary service did not treat the deceased with “dignity.”

The BBC said the refusal of some management to engage with the review led to the government announcing that the scope of Martha's Rule would be extended, and it noted that staff who refuse to engage could be compelled to give evidence or face up to two years in prison.

The BBC said Ockenden unveiled her findings at the Crowne Plaza hotel in Nottingham in front of bereaved and affected families, and it reported that her review team told the BBC that different care may have altered the outcome for 260 babies who died or were harmed.

“The three-year report, which outlines essential actions for NUH and national maternity services, was the based on the experiences of over 2,500 families across a decade who experienced serious failings, including avoidable deaths, stillbirths, neonatal deaths and life-changing injuries to both babies and mothers”

Healthcare Management Magazine

The Guardian reported that the review found a high number of mothers who received care from the trust experienced serious and severe complications, including 142 cases of fourth-degree perineal tears and 130 unexpected admissions to the intensive care unit (ITU).

The Guardian also reported that of the 27 maternal deaths reviewed, suboptimal care was identified in about a fifth (21.4%) of these cases, and it said more than a third (35.6%) of mothers admitted to intensive care experienced care graded suboptimal.

The Independent said health secretary James Murray apologised in the Commons on behalf of the NHS, which he said “catastrophically” failed families who “suffered so appallingly” under maternity services at the trust.

The BBC added that Ockenden said the service at NUH now was “not where it was, but it is not yet where it needs to be,” and it described the review as “a report about how a system failed, and what it costs when it fails.”