Nottingham University Hospitals NHS Trust maternity failures

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The report examined maternity and neonatal services at the NUH NHS Trust trust, detailing chronic staff shortages, lack of basic training and poor management.

The Independent Maternity Review, also known as the Ockenden Review, was published on the 24th of March 2026, led by Donna Ockenden with the assistance of a team of over 160 reviewers.

Individual meetings with over 500 families and 830+ current and former NUH staff took place over the course of the review. A full copy of this report can be found here.

Nottingham University Hospitals

What findings did the report uncover?

The review described a toxic culture of bullying at maternity units, ‘infected’ by a ‘small minority of powerful leaders’ who bullied staff and patients. Ockenden (an expert midwife) and her team documented a ‘persistent failure’ to believe mothers, and a failure to investigate and learn from mistakes. This resulted in needless grief and pain from death and injury during childbirth.

Some of the recorded incidents included:

At least 156 babies died
22 women died
Babies died of a range of conditions, including oxygen starvation, mismanaged labour, hospital infections, and poor Clinical postnatal care
Baby stored in the mortuary alongside an unidentified adult
Early gestation baby disposed of as clinical waste
Colour postmortem photos sent to grieving parents
A mother’s body incorrectly stored, leaving it too decomposed to be seen by relatives
One woman was told to terminate a baby, only to be told later that it was perfectly healthy
‘Long-standing and systemic failures in clinical governance’
High turnover of senior staff

Ms. Ockenden stated that many issues highlighted by her team’s report had been known about since at least 2010. 40% of the staff interviewed reported being victims of bullying, being too scared to speak up.

2,500 family cases were examined during the reporting process, spanning over a decade of time.

Failures in maternity and neonatal care

Such failures in neonatal care may have contributed to long-term brain injury and adverse neurodevelopmental outcomes in babies, with potentially avoidable outcomes for 444 of the maternity cases and 76 of the neonatal cases.

All of these were graded 2 or 3 for harm. Grade 2 means significant concerns, whereas grade 3 means major concerns. A grade three concern could be reasonably expected for a difference to be made with different management.

Of the 22 women who died, the review concluded that six of those might have resulted in a different outcome.

Other investigations underway

The General Medical Council and Nursing and Midwifery Council are also conducting investigations:

GMC is investigating 62 cases regarding doctors
NMC is looking at 96 fitness to practise cases regarding maternity care

What happened with the Care Quality Commission?

Last year the CQC ordered Nottingham University Hospitals NHS trust to pay £1.66 million after it pleaded guilty to six charges brought by the Care Quality Commission, concerning the failure to provide safe care and treatment to three mothers and their babies.

An apology from the Health Secretary

James Murray, the Health Secretary, made an apology in an address to the House of Commons:

“To all of those who have suffered so appallingly, I say today on behalf of the NHS, I am sorry.

“I am sorry, not just for the failures or the heartless and undignified treatment, but also because your cries of concern went unheard for too long.

“And so the government will act. We will act by taking immediate steps, including to expand Martha’s Rule to all maternity in neonatal settings, so that parents can demand a second opinion if they feel their concerns are being ignored.”

His full address can be read here.

Statement from The Royal College of Midwives’ Gill Walton

[The report exposes] “more than a decade of leadership and institutional failure.

“At the heart of that failure was a healthcare system that refused to listen to women, to families and to the midwives who were raising the alarm for years.

“Every woman and family deserves to be heard and treated with dignity and compassion. What happened in Nottingham fell devastatingly short of that.

“Toxic culture, poor behaviours, bullying and racism, have no place in maternity care or the NHS.”

The NUH Hospitals Trust responds

Finally, here is an excerpt from the NUH response in an open letter to the the people and communities of Nottinghamshire, penned by Chief Executive Anthony May and Trust Chair Nick Carver:

“The publication of the independent review into maternity services in Nottingham is a watershed moment for affected families, our staff and for the communities we serve.

“We apologise unreservedly to the women and 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.”

What do I do if I have experienced maternal, or any other kind of Medical Negligence?

Get in touch with our dedicated team of Medical Negligence specialists. Our team has many combined years of experience in such matters, and will compassionately speak to you about your personal circumstances in complete confidentiality.

There is no obligation to proceed by doing so, and this may be your first step in gaining a little more clarity about the direction you wish to take.

‘Largest maternity review in NHS history’ reveals failures at Nottingham University Hospitals NHS Trust