More than 500 mothers and babies suffered potentially avoidable harm or died at a single NHS hospital trust over more than a decade. That is the devastating conclusion of the largest maternity review in NHS history, led by senior midwife Donna Ockenden. The review focused on Nottingham University Hospitals NHS Trust (NUH), which runs Queen's Medical Centre and Nottingham City Hospital. It found a “bullying and toxic culture”, with leaders aware of serious issues for years but failing to act. A total of 444 women and 76 newborn babies had “potentially avoidable” outcomes, including 94 stillbirths, 62 neonatal deaths, and six maternal deaths where failures in care may have substantially impacted the outcome. The 401-page report, published on Wednesday, also revealed that different management could have altered the outcome for 260 babies who died or were harmed.
The review was commissioned after families warned that maternity care at NUH was unsafe. It gathered contributions from about 2,500 families and more than 800 staff. The report describes a “cruel” and dismissive attitude towards women, with some accused of “imagining pain” and turned away for help. Staff not listening to women or acting promptly on concerns was a common failure. There were also repeated failures to monitor babies properly, delays in scans, and mismanaged labour. A “quest” for vaginal births meant intervention was avoided, sometimes leading to “tragic outcomes”. The trust’s mortuary service failed to treat the deceased with dignity, with one baby’s dead body disposed of as clinical waste.
“Explains the largest NHS maternity review, which found over 500 cases of avoidable harm at a Nottingham trust.”
For UK readers, the scandal raises serious questions about patient safety across the NHS. It shows how systemic failures, weak leadership, and a culture that silences concerns can lead to catastrophic harm. The government has responded by extending Martha’s Rule—a scheme giving families 24/7 access to a second opinion—to all maternity units in England. It also plans to compel NHS staff who refuse to engage with maternity reviews to give evidence, facing up to two years in prison. However, enforcement details are not yet clear. Donna Ockenden stressed that safe maternity care requires “competence, honesty, timeliness, safety, dignity and kindness”, and that “a civilised NHS will be judged not only by the excellence it achieves, but by the harm it prevents.”
Q: What did the Ockenden review find about the Nottingham maternity scandal? The review found that 520 mothers and babies suffered potentially avoidable harm or death due to “deeply embedded systemic failures” at Nottingham University Hospitals NHS Trust. It identified a toxic bullying culture, leadership failures, and repeated instances where women’s concerns were dismissed.
Q: How many mothers and babies died or were harmed? A total of 444 women and 76 newborn babies had potentially avoidable outcomes. This includes 94 stillbirths, 62 neonatal deaths, six maternal deaths, 120 babies with brain injury, and nine children left with cerebral palsy. Thirty-one women suffered life-threatening obstetric bleeding.
Q: What changes are being made to prevent this happening again? The government is extending Martha’s Rule to all maternity units in England, giving families formal access to a second opinion. It also plans to compel NHS staff to give evidence to maternity reviews or face up to two years in prison. The trust has been fined £800,000 previously for failings.
What happens next? The government has announced that Martha’s Rule will be rolled out across all maternity and neonatal settings in England. Legislation is being prepared to compel NHS staff to cooperate with future reviews. The report is expected to lead to further investigations into other NHS trusts, as families and campaigners call for national change. Donna Ockenden urged that the voices of affected families become a “catalyst for lasting national change”.