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An Independent Review, published on 24th June 2026 and led by senior midwife Donna Ockenden, has exposed ‘systemic failings’ of maternity services at Nottingham University Hospitals NHS Trust (NUH), UK.
Findings of avoidable maternal and neonatal harm and death were revealed against a backdrop of a lack of reporting and investigation, dismissal of parental concerns, a toxic workplace culture and staff shortages, racial health inequalities, dehumanising post-mortem care, subsequent psychological trauma, and an overall “normalisation of deviance”.
Avoidable Harm and Death
The Review saw more than 2,500 families who received maternity and neonatal care at NUH between 2012 and 2025 come forward, as well as hearing evidence from more than 800 current or former staff.
Cases were scored from Grade 0 to Grade 3:
- Grade 0: Appropriate care in line with best practice at the time
- Grade 1: Minor concerns; care could have been improved but different management would have made no difference to the outcome
- Grade 2: Significant concerns; suboptimal care in which different management might have made a difference to the outcome
- Grade 3: Major concerns; suboptimal care in which different management would reasonably have been expected to have made a difference to the outcome
The investigation classed: 21.4% of maternal deaths, 26.1% of massive obstetric haemorrhages, 14.1% of 4th degree tears, 28.6% of pre-eclampsia cases, 35.6% of unexpected maternal admissions to ITU, 20.1% of a mothers’ care when a baby was stillborn, 50.3% of a mother’s care when a baby suffered hypoxic brain injury, and 12% of neonatal deaths as Grade 2 or 3.
Better care could have changed the outcomes, which were, therefore, preventable.
Inquiry chairwoman Ockenden reported on 24th June that maternity services at NUH “failed the people it existed to serve”, with the team finding the “normalisation of deviance” in maternal care.
Family Testimonies
The report heard testimonies from affected families who had been in contact with the maternity services at NUH.
In 2019, one early gestation baby was ‘inadvertently disposed of as clinical waste’ by laboratory staff after her post-mortem examination, causing a complete loss of dignity against the family’s express wishes: “We didn’t want the baby to be disposed of.
“That was the main thing we didn’t want.”
Dismissal was a common theme: “I told her that my baby hardly ever moved – she gave me the impression that she thought I was just busy and anxious and that it was my fault and because it was my first baby, I didn’t know what was normal.”
Issues in bereavement care were also acute: “There was no bereavement midwife available and no follow-up care – no counselling or even a phone call to see if we were okay.”
Where care was coordinated, unhurried, and compassionate, families described reassurance and support: “They would always see you immediately if there was a problem.”
One affected mother has described good staff as victims of the environment.
NUH Response
The NUH released an open letter to the people and communities of Nottinghamshire on 24th June.
In it, Chief Executive Anthony May and Trust Chair Nick Carver wrote: “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 of our failings.”
Recommendations
The report also outlined immediate and essential actions for the improvement of care and safety in maternal services across England, under eight key themes:
- Listening to women and families
- Workforce planning and safe staffing
- Training and multi-professional learning
- Risk assessment throughout pregnancy
- Incident investigation and family involvement
- Governance and board accountability
- Culture, teamwork and psychological safety
- Mothers who have died and post death care
The government has today committed to rolling out Martha’s Rule to all maternity setting in England, with a view to giving all hospital inpatients and their families the legal right to request a rapid, independent clinical review if a patient’s condition is deteriorating and they feel their concerns are not being listened to nor addressed by primary care teams.
Presenting findings of the Review today, Ockenden said: “I firmly believe that safe, compassionate, and equitable perinatal care is achievable in Nottingham and across England.
“But only if there is unwavering commitment, at every level of the system, to accountability, learning, transparency and, above all, to basic human kindness.
“We owe this to every one of the Nottingham families.”
Reference
Ockenden D. Findings, conclusions and essential actions from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust. Available at: https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2026/06/ockenden-report-review-of-maternity-services-nottingham-university-hospitals-nhs-trust-web-accessible.pdf. Last accessed: 24 June 2026.
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