The publication of Donna Ockenden’s review into maternity services at Nottingham University Hospitals NHS Trust has exposed one of the most serious patient safety failures in NHS history. The report found that more than 500 mothers and babies experienced potentially avoidable harm or death following failures in maternity care over many years.
For many affected families, the findings validate concerns that had been raised repeatedly but were not acted upon.
What did the Nottingham maternity review find?
Donna Ockenden’s independent review examined thousands of maternity cases involving Nottingham University Hospitals NHS Trust. More than 2,500 families and hundreds of current and former NHS staff contributed evidence during the investigation.
The findings identified potentially avoidable harm in 520 cases, including hundreds involving mothers and dozens involving newborn babies. The review concluded that repeated failures in clinical care contributed to preventable deaths, stillbirths, serious brain injuries, and maternal harm.
Among the recurring problems identified were:
- Failure to listen to women who raised concerns about their symptoms
- Delays in carrying out essential scans and recognising antenatal care red flags
- Incorrect interpretation of CTG monitoring during labour
- Failure to recognise signs of fetal distress
- Delays in escalating concerns to senior clinicians
- Poor management of labour and delivery
- Inadequate postnatal care
- Chronic staffing shortage
- A culture of bullying that discouraged staff from speaking up
- Failure to learn from previous patient safety incidents
The review also criticised aspects of bereavement care, highlighting distressing failures in the handling of babies after death and communication with grieving families.
Perhaps most concerning was the conclusion that many of these problems had been recognised internally for years, but meaningful improvements were not implemented.
Many of the failings identified in Nottingham closely mirror those uncovered during Donna Ockenden’s earlier review of Shrewsbury and Telford NHS Trust, where concerns were also raised about the prospect of criminal charges for maternity negligence following years of systemic failures.
A culture problem as well as a clinical one
The report makes clear that this was not simply a series of isolated medical errors. Investigators described a culture where concerns raised by women, families, and healthcare professionals were too often dismissed. Some mothers reported feeling ignored during labour, while others described interactions lacking compassion at some of the most vulnerable moments of their lives.
Senior leadership was criticised for failing to respond effectively to repeated warnings about patient safety. The review also noted that some former leaders declined to engage fully with the investigation, prompting the Government to announce stronger powers requiring NHS staff to cooperate with future maternity inquiries.
Alongside recommendations to improve staffing, training, and governance, the Government confirmed plans to expand Martha’s Rule across maternity services. The initiative is intended to give patients and families greater access to an independent clinical review if they believe concerns about care are not being addressed.
Seeking legal advice after maternity negligence
Many families affected by birth injuries or baby loss initially believe that what happened was simply unavoidable. Independent investigations often reveal a different picture.
Obtaining specialist legal advice can help establish whether care fell below acceptable professional standards and whether different treatment would probably have prevented the outcome.
If you have concerns about the maternity care you or your baby received, our specialist clinical negligence solicitors can assess whether you may have grounds for a claim against either the NHS or a private healthcare provider, offering clear advice with no obligation to proceed.