Donna Ockenden’s independent review of maternity services at Nottingham University Hospitals NHS Trust published

An independent review of maternity services at Nottingham University Hospitals NHS Trust has been carried out by Donna Ockenden, with her findings published on 24 June 2026. At its heart are the experiences of more than 2,500 families whose cases formed the basis of the largest maternity review in NHS history.

What emerge from the findings are not isolated errors, but a pattern of instances where staff and families’ concerns were ignored, opportunities to intervene were missed, and mistakes repeated.

The review identified hundreds of cases of potentially avoidable harm including those relating to 444 mothers and 76 newborn babies, including stillbirths, neonatal deaths, brain injuries, and serious maternal complications. The report concludes that these outcomes resulted from deep-rooted failures in culture, leadership, staffing, and governance over many years.

Key findings

The key findings set out in the report include:

• poor assessment and management of risk – including cases of delayed escalation of care when complications arose;
• failure to identify fetal distress and act promptly;
• inconsistent and unsafe clinical decision-making, especially in labour wards.

Causes of systemic failings identified

The systemic failings were found to stem from the following causes:

• Organisational culture – a ‘toxic’ organisational culture was identified, where concerns of clinicians were not listened to, and families’ concerns were dismissed or ignored. Staff reported difficulty speaking up or feeling that raising concerns would not lead to change. In several cases, parents’ instincts about reduced fetal movement or concerns of something not feeling right during labour were either dismissed or not acted on in time.
• Failures of governance and learning – there was a failure identified to take heed of repeated warning signs including incident reports, concerns of staff and families, and poor outcomes. Such warning signs should have led to urgent intervention and vital learning, but instead the issues were allowed to persist. Where internal investigations were carried out following incidents, these were often inadequate, and learning points were not embedded into practice which would have enabled meaningful change.
• Chronic staffing pressures and gaps in training – frequent understaffing was identified in maternity and neonatal services at the trust, with insufficient numbers of clinicians on shift to provide safe care to mothers and babies. Instances of gaps in staff training were evident, contributing to unsafe practices.

Rosie Nelson, senior associate in the medical negligence team at Penningtons Manches Cooper, comments: “The findings set out in Donna Ockenden’s latest report make for truly shocking reading. As a medical negligence solicitor, it is deeply concerning to learn that there were repeated failures to investigate incidents properly, meaning that mistakes were repeated, leading to further avoidable harm to families. Not only did those affected by the substandard care experience trauma at the time; they often had to fight to have their grievances acknowledged and be treated with the compassion and understanding they deserved.

“The report sends out a clear message that to keep mothers and babies safe, we need maternity services where staff are supported and sufficiently trained, families are carefully listened to, and where learning is embedded into practice following mistakes. I hope that this report will serve as a call to action, not just for this trust, but for NHS maternity services throughout the country. We cannot continue to fail families when they are at their most vulnerable.”