One baby girl who died early in gestation was “inadvertently disposed of as clinical waste by laboratory staff after her postmortem examination”, compounding her parents’ distress. She was one of 520 mothers and babies who suffered “potentially avoidable” harm or died at Nottingham University Hospitals NHS Trust (NUH), according to a damning three-year review by maternity safety expert Donna Ockenden.
In all, 444 women and 76 newborn babies were affected between 2012 and 2025, in what the report calls the biggest childbirth scandal in NHS history. Health Secretary James Murray described the findings as “horrific” and “chilling”, saying families suffered “dangerously and tragically deficient care at almost every turn” and “the NHS failed them catastrophically”.
“Report finds 520 mothers and babies suffered 'potentially avoidable' harm at Nottingham NHS trust amid bullying and toxic culture.”
Ockenden’s 401-page report paints a stark picture of “bullying and toxic culture” at NUH’s two hospitals, Queen’s Medical Centre and Nottingham City Hospital. Staff described “intimidating cliques” that were not challenged, and a “culture of organisational denial” where poor outcomes were regularly dismissed. Maternity service managers and senior leaders were repeatedly warned about serious problems but failed to take effective action.
Understaffing was routine, and the units could not cope with the number or complexity of births. The report found “a culture of not admitting women who were seeking admission in labour”, despite the risks. Lessons from patient safety incidents were not learned, and families were consistently not listened to, leading to missed opportunities to prevent harm.
Among the specific failures, the review examined 17 babies and one adult who died and found “recurring examples of failure to protect the dignity of the deceased”, including dehumanising language by clinicians and poor mortuary care. Babies died from oxygen starvation, mismanaged labour, hospital-acquired infections and poor postnatal care.
Sarah and Gary Andrews’ daughter Wynter died 23 minutes after being born in 2019. NUH was fined £800,000 in 2023 for failings in her care. “All we’ve wanted from the beginning is that no other families have to endure what we have,” said Sarah Andrews, 41. Sarah Hawkins, 43, whose baby Harriet died in 2016, told the BBC it was “soul-destroying” to learn the harm may have been preventable.
The Nottingham Maternity Families group, representing about 600 families, has asked Prime Minister Keir Starmer to establish a statutory public inquiry into failings across the entire NHS. Murray said the government is considering that request: “I don’t think we should take anything off the table at this stage.” He noted that some families want a public inquiry while others don’t, but all want accountability and change.
Ockenden said: “We owe it to every mother, every baby and every family whose terrible experiences are recorded here that they are never repeated.”