More than 500 mothers. babies came to harm or died as a result of inadequate care in Nottingham, an inquiry into the NHS’s biggest ever maternity scandal has revealed.
A total of 444 women. 76 newborn babies suffered “potentially avoidable” outcomes because they received substandard treatment over 13 years from Nottingham University hospitals NHS trust (NUH), a damning report led by the childbirth expert Donna Ockenden has found.
The 401-page document paints a stark. forensic 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. 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 impacted on the outcome in six deaths”.
Staff’s failure to listen to women. to act 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 starved of oxygen during birth or picking up a hospital-acquired infection, or because midwives. 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. that, if they had been handled differently, they would probably have avoided coming to harm.
The report lays bare a host of recurring failings in clinical care that put mothers. 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,
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.
The chair of the Nottingham University hospitals NHS trust, Nick Carver,. chief executive, Anthony May, have issued an open letter in response to the Ockenden report.
Addressed to “the people. communities of Nottinghamshire”, they apologised and said while improvements have been made, there is more to do.
Here is the letter in full:
double quotation mark The publication of the independent review into maternity services in Nottingham is a watershed moment for affected families, our staff. for the communities we serve. We apologise unreservedly to the women. 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.
Many families have been generous enough to meet with us, showing extraordinary courage and determination. We are grateful for that,. we want you to know that the publication of this report is not the end of a process. It is another important milestone in a journey that must continue. Your bravery and commitment to speaking up is helping improve maternity care.
We want to thank Donna Ockenden for her work and for engaging with us throughout this process. Donna’s review has provided an opportunity to hear directly from thousands of families and staff. The direct feedback we have had throughout has helped us with our improvement efforts. As a result, whilst there is more to do, important changes have been made. we believe our services are now safer, kinder and better led.
We recognise that trust is earned through actions, not words. We know, also, that families. the wider public will judge us not by what we say today, but by what we do next.
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. At the same time, we will work with families on a meaningful apology because we know it is important to them that this is reflective of the findings of the review,. our commitment to lasting improvement. We can say with certainty that families will continue to be involved in our improvement plans. this review has proved that we can learn from them.
We must also acknowledge our staff. Every day we see dedicated, compassionate professionals working tirelessly to provide the best possible care for women. families, often under extreme pressure and scrutiny. Whilst the publication of the report will be difficult for them too, we know they will reflect on the findings of the review. see this as an opportunity to continue our improvement journey. To these colleagues, we want to say that we know that we did not always provide you with the right conditions to do your jobs as you would wish. we take responsibility for that.
At Nottingham University Hospitals, we are determined to provide maternity services that are consistently safe, compassionate, equitable and responsive. We want every family to have confidence in the care they receive. We want to reassure anyone using our services today that you will be safe in our care.
On behalf of the trust, we renew the commitments to transparency, openness and accountability. Most importantly, we renew our commitment to providing safe, high-quality maternity care at your hospitals.”
Nottingham “does not exist in a vacuum”. Ockenden said at the press conference, as she warned of the “toxic culture” that took hold at Nottingham University hospitals NHS trust.
double quotation mark A pledge was made in 2015 to reduce the rates of stillbirths. maternal deaths in England by 50% by 2030. We are not on track.
Stillbirths, whilst reduced over recent years, remain above pre-Covid pandemic levels. Maternal deaths are at a 20-year high. the women most at risk, women living in the most deprived communities and black women, continue to die at rates that are a national scandal.”
That disparity is well known, but it has not narrowed.
double quotation mark What the evidence shows is that at Nottingham, a toxic culture was allowed to take hold. was allowed to persist.
A small number of powerful leaders, described in both family. staff testimonies as having infected the unit, created an environment in which bullying was normalised, speaking up was dangerous, and governance was shaped by self-protection rather than patient safety.
Midwives describe being intimidated in governance meetings, junior staff described to us being afraid to escalate. The incident review panel was described as intimidating, male-dominated and dismissive of non-medical voices over very many years.
Staff described to us leaving the trust because incidents were being brushed under the carpet.
Ockenden said the report also addresses “clearly and with evidence the inequalities that shaped who was most harmed”.
These included women from black, Asian. other minority ethnic backgrounds, those living in deprived areas of Nottingham and Nottinghamshire, women with mental health needs, and women who did not speak English as a first language.
“ These are amongst the women who face the greatest barriers to being heard,. who were most likely to have their concerns dismissed or minimised,” Ockenden said.
Presenting some of her findings. Ockenden said her team found “significant or major concerns in care where different or better care may have made a difference to the outcome” in the following cases:
21% of cases where mothers died,
26% of cases where mothers experienced a major obstetric haemorrhage,
36% of cases where a mother had an unplanned admission to intensive care,
20% of cases involving a mother’s care when a baby was stillborn,
50% of a mother’s care when a baby suffered hypoxic brain injury.
About 2,500 families gave evidence to the inquiry, which examined events from 2012 to 2025.
Ockenden said the report “is about what happens when leadership fails”.
She added: “This is a report about a system that failed,. it is a report about what it costs when systems fail.
“It costs lives. It costs futures, and it costs families everything.”
Speaking at the press conference on her findings. Donna Ockenden began by praising the Nottingham families who campaigned for years for justice.
double quotation mark More than 2,500 families came forward to share with my team what happened to them.
Let that number sit with you for a moment – 2,500 families.
Their experiences occurred over more than a decade. And yet the themes that run through those experiences. the failure to listen, a failure to investigate, a failure to learn are hauntingly consistent. From 2012 to 2025, year after year, baby after baby, mother after mother, family after family.
This review owes its very existence to a group of families who refused to be silenced. They came together in harm. in grief, united in their determination that what had happened to them should not happen to anyone else.
More than 500 mothers. babies came to harm or died as a result of inadequate care in Nottingham, an inquiry into the NHS’s biggest ever maternity scandal has revealed.
A total of 444 women. 76 newborn babies suffered “potentially avoidable” outcomes because they received substandard treatment over 13 years from Nottingham University hospitals NHS trust (NUH), a damning report led by the childbirth expert Donna Ockenden has found.
The 401-page document paints a stark. forensic 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. 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 impacted on the outcome in six deaths”.
Staff’s failure to listen to women. to act 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 starved of oxygen during birth or picking up a hospital-acquired infection, or because midwives. doctors did not manage the mother’s labour properly or provided poor postnatal care.
The press conference on the Ockenden inquiry has begun, you can watch live here:
Paula Sussex, the parliamentary. health service ombudsman, said the report “adds to an overwhelming body of evidence that maternity services are failing women and families in ways that are repeated and preventable”.
In remarks reported by the Press Association earlier this morning, she said:
double quotation mark For years, reviews have highlighted the same issues – failures in communication, not listening, delays in diagnosis,. poor postnatal care. Yet too often these warnings and any lessons have not translated into lasting improvement, resulting in repeated harm.
While many NHS staff work tirelessly to provide excellent care, every woman and baby deserves safe, compassionate care, every time. It is vital now that we focus on fixing the service. NHS leaders must ensure these findings lead to real, sustained action across all Trusts.
Listening to women and families is one of the most effective ways to prevent harm and improve care. We owe it to those affected not just to recognise these failures, but to ensure they lead to meaningful. lasting change.”
A photo from the newswire this morning of families arriving at the Crowne Plaza hotel in Nottingham for the Ockenden report press conference.
‘Truly horrific’: the stories of five people affected by the NHS maternity scandal
In this report by the Guardian’s social affairs correspondent. Jessica Murray, five families recount the devastating consequences of failures in maternity care at Nottingham university hospitals NHS trust.
Among them is Sarah Andrews. whose daughter, Wynter, died in 2019 at the Queen’s Medical Centre from hypoxic ischaemic encephalopathy – a loss of oxygen flow to the brain – which could have been prevented had staff delivered her earlier. Sharing her story, she said:
double quotation mark I went into labour. I was having contractions, and for six days, I was basically told to stay at home. I didn’t feel like I had any other choice. And then in hospital, the care was just beset by failures.
I actually said to my husband I felt like I’d be better off dead than in the situation I was in … It was truly horrific. When they eventually called the emergency C-section. opened me up, the smell of infection filled the room and that’s when they realised that Wynter was stuck in my pelvis. All the warning signs of infection were there.
Me and Gary had to watch for 23 minutes while they failed to resuscitate her. We had staff come visit us in the bereavement suite. they said it was one of those things, that sometimes babies die. One said to us: ‘If we listen to every mother’s concerns. we’d be overrun.’ They’re telling us that they can’t see anything that’s gone wrong. And a year later, at the inquest, the coroner rules that it’s a clear and obvious case of neglect.”
Speaking ahead of the publication of the report. Labour MP Michelle Welsh said it was “pure luck” that her own baby had survived birth.
“When it comes to luck, as to whether your baby survives or not, then that is a true indication of a system that is truly, truly failing,” the MP for Sherwood Forest. the government’s first maternity adviser told BBC Radio 4’s Today programme.
When asked whether there was a will within government to change things, she said:
double quotation mark I feel that there is a momentum. I do feel that there is a will.
I mean, I absolutely make sure that I am listened to. I haven’t got in within those doors to sit there quiet and just nod my head. I’m absolutely out there, at the forefront, being very, very loud. clear about the fact that we do need the funding.
But funding alone is not going to solve this crisis. There needs to be huge systematic change. The government has to be bold in the policies that it makes. because tinkering around the edges will not solve this crisis.
And some of these organisations involved are going to have to face these truths,. we are going to have to deal with this head on.”
The report of the largest maternity inquiry in the history of the NHS is due to be published today. is expected to outline widespread failings in the care provided to women in Nottingham.
As previously reported by the Guardian, the report will reveal a catalogue of appalling behaviour over many years by staff at the city’s two hospitals – Queen’s Medical Centre. Nottingham city hospital – including racism towards mothers.
The inquiry, led by senior midwife Donna Ockenden, investigated 2,500 cases of stillbirths, neonatal deaths, maternal deaths. babies or mothers who suffered brain damage and other injuries while under the care of Nottingham university hospitals NHS trust between 1 April 2012 and 31 May 2025.
A senior source with knowledge of Ockenden’s conclusions said: “The findings in the Nottingham report will be very bad. It’s going to be horrendous. There will be some pretty challenging stuff in the report.”
The inquiry began more than four years ago, in May 2022, following a decade-long campaign for justice. change by the families affected. More than 2,500 families and approximately 850 staff and ex-staff of the NHS trust have given evidence to it.
Nottinghamshire police is still considering whether to charge the trust with corporate manslaughter. On Monday. the police force said two men were arrested “in connection with operating practices in the mortuary service” provided by the trust. It is thought to be the first arrests as part of the force’s Operation Perth. which has been examining care provided to at least 200 families.
The Guardian’s health policy editor, Denis Campbell, and health and inequalities correspondent, Tobi Thomas, have more:
The report is expected to be published at 11.45am with Ockenden to give a press conference at the Crowne Plaza hotel in Nottingham. Follow along to get the latest updates.
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