‘Horrific’ maternity care failings at Nottingham NHS trust prompt calls for public inquiry | NHS

The appalling failures left 520 mothers and babies harmed or killed in Nottingham and sparked calls for a public inquiry into maternity care across England.

In total, 444 women and 76 newborn babies faced “potentially preventable” consequences. three year review The biggest maternity scandal in NHS history has been concluded.

Health minister James Murray said the nature and scale of the failings revealed in Donna Ockenden’s report into maternity services at Nottingham University hospitals NHS Trust (NUH) between 2012 and 2025 were “appalling” and “chilling”.

Murray said families were “exposed to dangerous and tragically inadequate care at almost every turn” and that “the NHS is leaving them facing disaster”. She was “devastated” and “heartbroken” when she read Ockenden’s 401-page statement about the “neglect, incompetence, racism, discrimination, humiliation and harassment suffered by so many.”

Ockenden, a respected birth safety expert, has painted a clear and detailed picture of maternity care at NUH’s two hospitals, Queen’s medical center and Nottingham city hospital. It found that “multiple” women there faced dangerously poor and sometimes “brutal” care, understaffing was routine, lessons were not learned from patient safety incidents, and bullying by “scare cliques” of staff was common.

The Nottingham Birth Families group, which represents nearly 600 damaged and bereaved families, has asked Keir Starmer to establish a statutory public inquiry to investigate failures in maternity and newborn care across the NHS because “safe care can only be consistently provided when the full truth is known”.

Murray said the government is considering the request. “I don’t think we should take anything off the table at this stage,” he said when pressed on the possibility of such an investigation.

However, he stressed that not all affected families supported such a move. “When I spoke to families, some wanted a public inquiry, others had a different view, but what united all the families I spoke to was a desire for accountability and a desire to see change in the way maternity services are delivered so that women can be heard,” she said.

Ockenden and her team of obstetricians investigated the deaths of 27 mothers between 2006 and 2024 and “identified failures in care that may have affected or significantly affected the outcome of six deaths.”

It found that staff’s failure to listen to women or act promptly on concerns they raised was one of the “widespread failures” in maternal deaths and delays in women getting screened.

The then health secretary, Sajid Javid, ordered the review in 2022 after families warned that maternity care in NUH care was unsafe. Also examined were cases where babies died during birth due to lack of oxygen or a hospital-acquired infection, or when midwives and doctors failed to properly manage the mother’s labor or where postnatal care was inadequate.

A detailed examination of the deaths of 31 newborn babies revealed that these babies had received inadequate care and would probably not have been harmed had they been handled differently.

The report reveals a series of repeated failures in clinical care that put mothers and babies at risk and, in some cases, resulted in disaster. These include failure to properly monitor babies during birth, misinterpretation of CTG monitoring as to the baby’s health while still in the womb, failure to recognize when babies are in distress, and midwives’ failure to urgently refer worrying cases to doctors to make quick decisions about the care and treatment needed.

“In some cases, these failures led to serious neonatal injuries, stillbirths, and neonatal deaths,” the report said.

In total, 2,536 families and 838 current or former NUH staff gave evidence to the review team. He also found:

• A “culture of bullying and toxicity” that persisted for many years at NUH hindered steps to improve care.

• Maternity services managers and senior leaders of the trust were repeatedly warned about serious problems in the maternity units of both hospitals, but took no effective action.

• Birth room staff exhibited a “culture of not accepting women who wanted to go into labor” despite the risks it posed to themselves and their babies.

• Both maternity units were constantly under severe staff shortages and were unable to cope with the number of births and the complexity of the cases they had to deal with.

• The parents’ distress was further compounded by the fact that a girl who died early in pregnancy was “mistakenly disposed of as clinical waste by laboratory staff following postmortem examination.”

Families told Ockenden about their horrific experiences. Some were given no or very little pain relief. “It was brutal… traumatic… They were screaming at me, ‘You need to pull yourself together,'” one woman said.

Behavior Ockenden said was sometimes “cruel” and lacking in compassion, with staff able to ignore women’s concerns. One said she was told: “Is this your first baby? Take some paracetamol and take a warm bath.”

The Nottingham Maternity Families group said the need for a full public inquiry, with the power to compel witnesses to attend, was highlighted by the “appalling” refusal of many senior figures at the trust and the local NHS bodies that oversee it to speak to Ockenden.

Almost half of the 66 current and former NUH executives it asked to take part in the inquiry did not do so, despite many being asked “more than once”. Reaction among leaders on the NHS clinical commissioning group and integrated care boards was even worse; Only four of 14 people contacted spoke.

Ockenden described the trust as dysfunctional, poorly managed and determined to hide from the public the dangerous truth about care in maternity units.

Families also described it as “appalling” that many NUH senior managers chose not to give evidence to the inquiry and suggested they be sacked.

“You have demonstrated that the safety of motherhood is not important to you, but that protecting yourself is. Your failure to engage constructively and wholeheartedly in this review process is further evidence that you are unfit to keep mothers and babies safe.”

“You need to be asked by senior leaders and regulators whether you are suitable to work in the NHS,” they said in a statement.

Ockenden’s report described how Jack and Sarah Hawkins were subjected to “withholding of information” by the NUH and various regulatory bodies as they sought the truth about why their daughter Harriet died just before her birth in 2016.

Kim Thomas, chief executive of the Birth Trauma Association, said Ockenden’s “shocking” report showed “when complaints are made the trust’s instinct is to cover up failures rather than investigate them”.

“Sadly we believe Nottingham is not unique. As a charity we hear similar stories from hospitals across the country,” he added.

Murray announced that the Martha rule, which gives patients the right to an independent second opinion on their care by a separate clinical team, would be implemented in every maternity unit in England, as suggested by Ockenden.

In future, current or past NHS staff who refuse to give evidence at maternity inquests will be forced to do so to break the ingrained “culture of silence” that often accompanies neglect of care and medical negligence, or risk being imprisoned for up to two years.

Ockenden is leading Nottingham-style reviews into what families say are widespread failings in NHS maternity care in Leeds and Sussex.

In an open letter “to the people and communities of Nottinghamshire”, NUH chief executive Anthony May and chief executive Nick Carver said: “We apologize unreservedly to any women and families who have suffered harm, loss, trauma or distress while receiving care on our services.”

Murray promised the government and NHS bosses would “deliver lasting change” to improve maternity services across England. Ockenden’s findings will help inform an action plan to overhaul maternity services, which the Department of Health and Social Care’s maternity task force is preparing.