An independent review of maternity care failings at Nottingham hospitals has identified multiple issues with staffing, governance and workplace culture.

Senior midwife Donna Ockenden undertook an inquiry into around 2,500 cases of stillbirth, neonatal deaths and maternal deaths between April 2012 and May 2025.

She found that senior staff at Nottingham University Hospitals NHS Trust (NUH) prioritised “institutional reputation over patient safety”, meaning junior staff were often afraid to escalate concerns.

Bullying was normalised and speaking up was described as “dangerous” in her 400-page report. The hospital’s incident review panel was “intimidating and male-dominated”.

Alongside a culture that was described as “toxic”, understaffing was a major issue. Only 11% of those surveyed for the report said there were sufficient staff for the workload.

More than 40% said they had either witnessed or personally experienced bullying by managers or colleagues, and some staff were accused of forming “intimidating cliques” that were never confronted or challenged.

Ockenden concluded that more than 500 mothers and babies suffered potentially avoidable harm. Some 162 deaths, including 156 children and six mothers, could have been avoided if they had been given better care.

Families of babies who died or were left disabled due to mistakes at NUH attended the launch of the report today (24 June), with many in tears as the findings were delivered.

The report details horrific stories of women who were told to “pull themselves together” during labour, babies being labelled as specimens or samples, and families not being notified when failings were discovered.

Around 800 former and current members of staff at the trust were asked to provide input to the inquiry.

They raised a range of issues regarding the management culture, including that managers were often “invisible, unapproachable and unresponsive”, that they ignored concerns raised and that there was high turnover.

Patients also gave a number of positive accounts of staff for their compassion and skill, and 58% of survey respondents said that people support each other and work as a team.

Ockenden noted that a 2006 merger between Queens Medical Centre and Nottingham City Hospital to form NUH had proven culturally challenging right up to 2021, with the hospitals still culturally siloed and uncollaborative.

The report makes a number of recommendations on how NUH – and Trusts across the country – can improve maternity care.

For NUH, it calls for improved staff training, better pathways for staff to report concerns, and better monitoring of babies to ensure interventions are made quickly. It also calls for improvements in leadership, culture and training more generally across the trust.

Nationally, it recommended that hospitals implement Martha’s Rule, which gives families and patients the right to request a rapid review if they feel a condition is worsening. The Department of Health and Social Care today said it would follow this recommendation.

Ockenden’s report also urges the health service to invest in staffing to ensure maternity and neonatal units can cope with workload and meet standards.

It called for trusts to conduct and publish the findings of regular surveys highlighting job pressures such as workloads, understaffing or bullying behaviours.

“Culture is also something that relies on every member of the team, accountability and reflexivity is required alongside the foundations of workforce and time to lead,” it stated.

“Continued investment in restorative practices, multi-professional leadership, and staff engagement is essential to embed a sustainable culture of compassion and to ensure safe, high-quality care for women, babies, and families.”

Health secretary James Murray apologised to the families affected. In the House of Commons, he said: “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.”

The review into NUH follows on from previous maternity reviews in Leeds and Shrewsbury, which Ockenden also chaired.

She said: “While this work builds on learning from previous national maternity reviews, the scale and depth of evidence gathered in this review has provided further insight into patterns of harm, organisational culture, inequalities in maternity provision, and the care provided to families following the death of babies or mothers.”

Following the publication of the report, NUH chairman Nick Carver and chief executive Anthony May issued an open letter to “the people and communities of Nottinghamshire”.

It said: “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.”

The letter added that there are “dedicated, compassionate professionals working tirelessly to provide the best possible care for women and families”.

“Whilst the publication of the report will be difficult for them too, we know they will reflect on the findings of the review and see this as an opportunity to continue our improvement journey.

“To these colleagues, we want to say that we know that we did not always provide you with the right conditions to do your jobs as you would wish and we take responsibility for that.”

 

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