The failings of Nottingham University Hospitals NHS Trust maternity unit have been laid bare, with women from poorer or minority backgrounds most failed.
The independent review into maternity failings at Nottingham University Hospitals NHS Trust (NUH), led by senior midwife Donna Ockenden, was as bleak as expected. “This is a report about how a system failed and what it costs when it fails. It costs lives, futures and families, everything,” she said at a press conference,
Based on a review of more than 2,500 family cases that formed part of this investigation, as many as 444 women and 76 newborn babies suffered “potentially avoidable” outcomes because they received substandard treatment from NUH from 2012 to 2025. Even more shockingly, Ockenham underlined that many of the issues in the review were known by the Trust since at least 2010. Certainly, nothing the review found should have been a surprise. In its latest inspection in April, the Care Quality Commission yet again rated maternity services at the Trust as “requires improvement”.
The review says that better care would have made a difference to the outcome in 21% of cases where mothers died, 26% of cases where mothers experienced a major obstetric haemorrhage, 36% of cases where a mother had an unplanned admission to intensive care, and 20% of cases involving a mother’s care when a baby was stillborn.
Staffing levels were the most significant issue raised, with only 11% reporting enough staff for the workload. What the review calls “a long-running theme” was the Trust’s bullying and toxic culture. More than 40% of those questioned had either seen or experienced bullying by managers.
“Stillbirths, whilst reduced over recent years, remain above pre-COVID pandemic levels. Maternal deaths are at a 20-year high and the women most at risk, women living in the most deprived communities and black women, continue to die at rates that are a national scandal,” said Ockenden.
In particular, the review shines a spotlight on the inequality of help given at the Trust. Those most harmed were women from minority backgrounds, those from less economically well-off backgrounds, women with mental health issues, and those who did not speak English as a first language.
Watershed moment
“Donna Ockenden’s review is a stark reminder of the devastating consequences when women, families and frontline staff are not listened to. The experiences of the Nottingham families must be a catalyst for lasting change across maternity and neonatal services,” said Michelle Welsh, the government’s first maternity adviser.
Alison Wright, president of the Royal College of Obstetricians and Gynaecologists, said that the review “adds to the weight of evidence showing that safe staffing levels, dedicated time for staff training, and modern maternity facilities are not optional extras.”
Her sentiments were echoed by Chris Graham, Group CEO at international charity Picker, which is commissioned by the Care Quality Commission (CQC) to deliver the maternity survey, called the review “painful reading”
“It is clear that urgent improvements are needed in maternity and neonatal services across the country,” he said.
“We’ve introduced new national clinical standards which are helping prevent harm and ensure women get urgent maternity care more quickly, and local leaders and staff in Nottingham are working hard to address these failings. However, this report shows the scale of what still needs to change,” said Kate Brintworth, chief midwifery officer for England.
The response from the Trust itself was immediate. In an open letter after the review was published, NUH chairman Nick Carver and chief executive Anthony May apologised unreservedly and called the publication a “watershed moment for affected families, our staff and for the communities we serve”.
“We failed you, and on behalf of Nottingham University Hospitals Trust, we accept responsibility for our failings,” they continued.
Rolling out Martha’s Rule
NUH is taking immediate action, introducing a new helpline for concerned members of the public available from today. But the most immediate effect of the review is that the government has committed to rolling out Martha’s Rule across maternity and neonatal wards in England to ensure every parent can request a rapid review from an independent medical team if a baby’s or mother’s condition is deteriorating and they are concerned this is not being responded to.
As Healthcare Today has reported, the scheme – which is helping transform the NHS’ culture and has been rolled out for inpatients in every acute hospital in England – has already been piloted in 15 maternity and neonatal settings, with rollout to more expected this year.
Latest NHS England data shows that between September 2024 and February this year, 1,781 calls were made by hospital staff to Martha’s Rule helplines at their trusts to trigger a rapid review of care, as the health service continues to transform its culture to improve safety.
The government emphasised that those responsible for failures will be compelled to give evidence to investigations into failing maternity care to end a culture of secrecy and prevent further harm.
The measures are designed to tackle the culture of silence exposed by the Nottingham review, where more than 800 staff gave evidence, but many described a culture of being silenced by senior clinicians and hospital bosses when raising concerns around patient safety.
“Donna Ockenden’s review lays bare a culture where too many voices went unheard, too many opportunities to prevent harm were missed, and too many lives were lost. That’s why we have to take action, and quickly,” said health secretary James Murray.
