Babies and mothers died after ‘systemic and sustained’ failings, largest NHS maternity review finds

ByLaura Hammond and George TorrEast Midlands

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.

Led by senior midwife Donna Ockenden, the inquiry – the largest of its kind in NHS history – found leaders at Nottingham University Hospitals (NUH) NHS Trust knew there were serious issues at its maternity department going back years, but failed to take action.

When her review was published on Wednesday, it also revealed different care may have altered the outcome for 260 babies who died or were harmed.

Ockenden said: “This is a report about how a system failed, and what it costs when it fails. It costs lives, futures and families, everything.”

More on the Nottingham maternity scandal

About 2,500 families and more than 800 members of staff contributed to the review, which started in 2022.

But Ockenden said there were “gaps” in knowledge, because some senior leaders declined to engage with her review.

The report said 66 former and current senior colleagues were approached by the chief executive of the trust, of which 37 came forward and 35 were interviewed.

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

All of these 520 cases were graded as two or three for harm, with grade three representing “significant concerns” and grade three “major concerns” over care.

Grade two represents sub-optimal care, in which different management might have made a difference to the outcome, grade three is where different management would reasonably be expected to have made a difference.

The refusal of some management to engage in the review led to the government announcing that the scope of Martha’s Rule would be extended in a bid to boost accountability and safety for mothers and babies.

Other measures include ensuring NHS staff – past and present – who refuse to engage with upcoming maternity reviews are compelled to give evidence, or face up to two years in prison, although it is not yet clear how this will be enforced.

Ockenden unveiled the findings of her review at the Crowne Plaza hotel in Nottingham, in front of a number of bereaved and affected families.

Her review team told the BBC that different care may have altered the outcome for 260 babies who died or were harmed. Of that number, 155 babies died while 105 suffered serious injury due to substandard care.

Ockenden said many of the problems detailed in her report had been known about at NUH since “at least 2010”.

These include insufficient staffing, and the inability of staff to carry out basic and often mandatory training.

She also highlighted a “persistent failure to listen to and believe mothers and fathers” – as well as a failure to investigate, and therefore learn from, mistakes.

Ockenden said women’s consent was not sought during labour and some interaction from staff was at times “cruel”.

Women in labour were told to “pull themselves together” while another submission from a mother recalled how she was told to “wait their turn” as there was “other women they had to sort”.

Serious failings in post-death care were also highlighted, including concerns related to loss of dignity, poor mortuary processes, ineffective identification systems and inappropriate communication.

In the report, Ockenden outlined an incident in 2019 when “one very early gestation baby was inadvertently disposed as clinical waste by laboratory staff after her post-mortem examination, resulting in a complete loss of dignity for the baby and significant distress to her parents”.

Another “very serious incident” happened three years later, she said, involving the release of the wrong baby to a funeral director.

Ockenden said the service at NUH now was “not where it was, but it is not yet where it needs to be”.

Drawing her presentation to a close, she said: “We owe it to every mother and baby whose terrible experiences are recorded to be sure these failures here are never repeated.

“Time for talking and reflecting has passed this needs collective action, sustained action and renewed confidence.

“The families of Nottingham have shown extraordinary determination and courage in the face of devastating consequences which has marked their lives – they did this so what happened to them does not happen to anyone else.”

‘Cover-up was horrific’

Speaking during a press conference after Ockenden’s presentation, Dr Jack Hawkins – whose daughter Harriet was stillborn at Nottingham City Hospital in 2016 – said actions for learning identified in the review “must be treated with the utmost seriousness”.

He said: “Some of the themes identified are ones that we had direct and personal experience of – our concerns were dismissed and not acted upon – we were not told the truth, even after death.

“The hospital frequently failed to keep our loved ones safe.”

Sarah Hawkins – Harriet’s mother and a whistleblower of the maternity scandal – said she felt let down by those who cared for her.

Sarah was a senior physiotherapist and Jack was a consultant doctor.

She said: “We dedicated our careers to the NHS – I thought I would trust my colleagues – I was low risk. Then to be treated during my six-day labour like I was, I couldn’t compute it.

“After Harriet died – the cover-up was horrific, we knew this because we knew the system.”

During the press conference, Jack called for a statutory public inquiry.

Meanwhile, Health Secretary James Murray said “no options are off the table” when questioned on the issue in the House of Commons.

Murray, who met families taking part in the maternity review last week, had been addressing Ockenden’s report, which he said contained revelations that were “chilling” and “horrific”.

“I felt numb after hearing the depth of their pain,” he said.

“I felt even more numb when I considered how many families not in the room went through such trauma too, and the forgotten children who survived but lived with the consequences of failings in maternity care every day.”

Murray, who said he would be speaking to NUH chief executive Anthony May next week, added the “government will act”.

In a statement the Nottingham Maternity Families Group said: “It feels like there is no aspect of maternity and neonatal services that has come out of this review unscathed.

“Some of the themes identified in the report are ones that we, the campaign families, have direct and personal experience of. Our concerns were dismissed and not acted upon; we weren’t told the truth about what happened; even after death babies were treated with an absence of dignity and NUH frequently failed to keep our loved ones safe.

“The report findings and actions that Donna and her team say must happen, must be treated with the utmost seriousness and implemented in full. Anything less would be a betrayal of the families whose suffering has made this review necessary.”

After the publication of Ockenden’s report, it was announced that Martha’s Rule – which guarantees patients the right to an urgent rapid review of their care – is to be rolled out to maternity settings.

In response to the review, NUH chairman Nick Carver and chief executive May issued an open letter, addressed to “the people and communities of Nottinghamshire”.

In it, they apologised “unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services”.

The letter added: “We recognise that trust is earned through actions, not words. We know, also, that families and 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, and our commitment to lasting improvement.”

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