The publication of Donna Ockenden's final report into the review into maternity services at Nottingham University Hospitals NHS Trust represents a watershed moment for maternity care in England.
As the largest maternity investigation in NHS history, the review examined approximately 2,500 cases involving stillbirths, neonatal deaths, maternal deaths and serious injuries to mothers and babies. It follows years of campaigning by families who sought answers after experiencing devastating outcomes and feeling that their concerns had not been properly acknowledged or investigated.
The result is a report that lays bare a series of systemic failures extending over more than a decade and raises important questions about patient safety, organisational culture, accountability and learning across NHS maternity services.
A Review Driven by Families
At the heart of the review are thousands of families whose lives have been changed forever.
Many described feeling ignored when raising concerns during pregnancy, labour or the postnatal period. Others spoke of long struggles to obtain answers about what had happened to them or their babies. The review stands as a testament to the determination of those families, whose persistence ultimately led to one of the most significant investigations ever undertaken within the NHS.
Their experiences serve as a powerful reminder that transparency, honesty and meaningful engagement with families must remain central to safe maternity care.
The Scale of the Findings
One of the most striking aspects of the review is the sheer scale of the concerns identified.
The review reportedly found more than 440 cases where there were either "significant" or "major" concerns regarding the maternity care provided. In several cases, failures in care may have contributed to avoidable deaths, long-term brain injuries and adverse neurodevelopmental outcomes in babies.
For many families, the publication of the report represents the culmination of years of campaigning to have their experiences acknowledged and properly investigated. Whilst every case is unique, the review identifies recurring themes and repeated missed opportunities to prevent harm.
Failure to Listen to Women and Families
One of the most consistent findings is the failure to listen to women and their families.
Throughout the review, women described concerns that were dismissed, symptoms that were not adequately investigated and opportunities for escalation that were missed. Families frequently reported feeling excluded from decision-making and inadequately informed during some of the most critical moments of their lives.
Listening to women is not simply a matter of patient experience. It is a patient safety issue. Women and their families are often the first to recognise when something is wrong, and maternity services must create environments in which concerns are heard, valued and acted upon.
As Donna Ockenden succinctly puts it: “what happened here cannot be allowed to remain in the shadows….[families] deserve at the very least the truth”
Delays in Recognition and Escalation
The review highlights repeated concerns regarding delayed recognition of deterioration and failures to escalate care when complications arose.
In maternity care, timely decision-making can be critical. Delays in identifying fetal distress, maternal deterioration or developing complications can have profound consequences for both mother and baby.
The report identifies numerous examples where opportunities existed to intervene earlier, potentially altering outcomes and preventing avoidable harm.
Organisational Culture and Leadership
Perhaps one of the most concerning aspects of the review is its description of the organisational culture that developed within the Trust.
The report describes a culture in which women and families frequently felt dismissed, concerns were not always taken seriously and opportunities to learn from adverse outcomes were repeatedly missed. Staff have also described environments in which speaking up could be difficult and where poor practice became normalised.
One of the most significant findings of this report is what did or did not happen when things went wrong. There is a high proportion of cases that should have had an investigation and learning. Of those unreported cases, over 100 involved significant or major concerns in care: serious incidents that were never classified as such. Families were never told what happened to them, and opportunities to prevent future harm were not taken. The Ockenden Review’s findings were that this was not accidental - the review team found persistent structural misapplication of grading of harm.
Midwives raising concerns were told to “close it off” and that it did not meet the threshold for a serious incident; so that families who should have been told the truth were not told until many years later or until they instructed lawyers to investigate. Some families are still waiting for answers.
“What the evidence shows is that a toxic culture took hold and was allowed to persist. This created an environment where speaking up was dangerous and governance was shaped by self-protection rather than patient safety.”
The report records that some members of staff chose to leave the Trust because they felt serious incidents were not being properly addressed, and concerns were, in effect, being overlooked. Importantly, however, the review makes clear that its findings should not be viewed as a criticism of all those who worked within the maternity service. Many dedicated healthcare professionals continued to provide excellent care under challenging circumstances, and their commitment, professionalism and compassion deserve recognition and respect.
Equality, Inclusion and Respect
According to the report, women from Black, Asian and other minority backgrounds, women from deprived areas, women whose first language is not English and women with mental health issues faced the greatest barriers to being heard and who were most likely to have their concerns dismissed or minimised.
Some families described experiences of discrimination and dismissive attitudes.
Safe maternity care is not solely about clinical competence. It also requires women to feel heard, respected and empowered to raise concerns throughout pregnancy, labour and the postnatal period. The report reinforces the importance of ensuring that all women receive equitable care regardless of background or ethnicity.
Lessons for Maternity Services Nationwide
The Nottingham review is not simply a report about one NHS Trust. It is a warning about what can happen when concerns are not listened to, when opportunities for learning are missed, and when organisational culture becomes a barrier to patient safety. While the events examined by the review relate to Nottingham, many of the themes identified have been echoed in previous maternity investigations across England. The challenge now is to ensure that these findings lead not merely to reflection, but to meaningful and lasting change for women, babies and families across the NHS.
Why Accountability Matters
For many families, the publication of the report will represent an important step towards understanding what happened and having their experiences recognised.
However, accountability is about more than identifying failings. It is about learning lessons and preventing future harm.
Where avoidable injuries occur, families often face significant emotional, practical and financial challenges. Access to independent advice, rehabilitation, support services and appropriate compensation can play an important role in helping individuals rebuild their lives and secure their future needs.
Looking Forward
The Ockenden Review is the most significant examination of maternity care ever undertaken in the United Kingdom.
Its findings are difficult reading. They tell the stories of families whose lives have been irrevocably changed and highlight serious shortcomings in the systems designed to keep mothers and babies safe.
Yet the review also provides an opportunity.
If its recommendations are embraced, if organisations are prepared to listen, and if patient safety remains the overriding priority, the experiences of the families involved can help drive meaningful and lasting improvements in maternity care.
The report sets out local actions for learning for the Trust and 8 areas of immediate and essential actions for maternity services that apply across England. Donna Ockenden made it clear that these are not aspirational. They are essential and they must be implemented.
They include:
- Listening to women and families as the foundation of everything associated with perinatal (at the time surrounding labour and delivery) care.
- Perinatal workforce planning and funded safe staffing without which no other improvement is possible.
- Training and multi-professional learning.
- Escalation and clinical oversight.
- Risk assessment throughout pregnancy.
- Incident investigation and family involvement.
- Governance and board accountability.
- Culture, teamwork and psychological safety.
Donna Ockenden observed that: “At the heart of [these essential actions]…is one clear principle where women, families or staff have ongoing concerns about a mother or baby they must be able to seek an urgent additional clinical review through clear accessible and responsive routes under the principles of Martha’s Rule in both hospital and in the community.”
She went on to say: “there are some grounds for hope here in Nottingham. I want to be honest about this because it matters. Since 2022 there are signs of positive change at NUH. Incident grading and investigation has improved…The progress that has been made must be sustained, deepened and built upon.”
“In conclusion, a civilised health service will be judged not only by the excellence it achieves but by the harm it prevents. In maternity care where trust is absolute and vulnerability acute, families carry consequences which are carried across lifetimes. I have spent years now listening to what those consequences look like….the loss of all that follows…the lost years of what might have been had safe and appropriate care been provided. Safe maternity care is not complicated in its ambition. We owe it to every mother, every baby….to ensure the failures described here are never repeated. The times for reflection and talking has passed. This must be a moment of collective action, sustained improvement and renewed confidence in the perinatal care that women and babies in England will receive… there needs to be an unwavering commitment to accountability, learning, transparency and to above all basic human kindness.”
Donna Ockenden concluded with a heartfelt and moving minute’s silence to remember the mothers and babies who have died or been harmed as the result of poor care.
In conclusion, the true legacy of the Ockenden Report will not be measured by the publication of the report itself, but by the extent to which its lessons lead to safer care for women, babies and families in the years ahead.
Hannah Carr, Legal Director and Specialist Medical Negligence Solicitor from MDS, said “Behind every finding in this report is a family whose life has been profoundly affected. The courage and determination of those families in seeking answers has brought issues of national importance into the spotlight. The challenge now is to ensure that the lessons identified by the Ockenden Report lead to genuine accountability, meaningful improvements in maternity care and safer outcomes for women and babies in the future.”
What should I do if I am concerned about the Maternity Care I have received?
Zephyr’s supports families in Nottingham following pregnancy loss, or the death of a baby or child. Contact them if you or a loved one needs support following the release of the Ockenden Report.
