Hundreds of Nottingham babies and mothers died after ‘systemic’ failings

Nearly 2,500 families and more than 800 staff contributed to the review, which began in 2022.

But Ockenden said there were “gaps” in the information because some senior leaders refused to participate in his review.

The report said 66 former and current senior colleagues were interviewed by the foundation’s chief executive, of whom 37 came forward and 35 were interviewed.

But experts involved in the review concluded there were “potentially preventable” consequences in 76 newborn cases, as well as 444 birth cases examined up to May 2025.

All of these 520 cases were rated two or three for harm; grade three represented “major concerns” and grade three represented “major concerns” regarding care.

Grade two represents suboptimal care where different management could make a difference in outcome; The third degree is where different management could reasonably be expected to make a difference.

The refusal of some administrators to participate in the review led the government to announce that the scope of the Martha Rule would be expanded to increase accountability and safety for mothers and babies.

Other measures include requiring past and present NHS staff who refuse to attend upcoming maternity exams to be forced to give evidence or face up to two years in prison; but it is not yet clear how this will be implemented.