The Ockenden Report, an investigation into maternity services at Nottingham University Hospitals NHS Trust (NUH), has laid bare the devastating consequences of long-standing failures in maternity care.
The review is the largest maternity investigation in NHS history and was led and centred on mothers, fathers and families who went through the Trust’s maternity services between 2012 and 2025. More than 2,000 births were reviewed and found that more than 500 mothers and babies suffered potentially avoidable harm over many years due to serious and systemic failings.
Although the findings focus on Nottingham, the report makes clear that many of the issues identified are not unique to this Trust. Instead, they reflect wider concerns about maternity care across England and raise important questions about safety, accountability and learning across the NHS.
What Did the Review Find?
The report is over 400 pages detailing many sad and heartbreaking stories from families affected as well as testimonies from some of the 800+ members of maternity services’ staff who also got involved. The report acknowledges that there is some positive and high-quality clinical practice, experience and service provided. Unfortunately much of this is undermined by the clear weaknesses and issues identified.
Many mothers, fathers and families reported not being listened to when they raised concerns about their health or their baby’s wellbeing at various stages of labour, delivery and postpartum care. Others felt they were not given enough information to make informed decisions about their care and that important choices were made for them rather than with them. Some reported insensitive and uncaring treatment in the cases where their experience sadly resulted in a fatal outcome.
The report also highlights:
- Chronic staffing shortages across NUH maternity services;
- Delays in responding to emergencies and deteriorating conditions;
- Poor communication between healthcare professionals;
- Inadequate support during labour, after birth and sometimes in post-death care;
- Unkind, dismissive or disrespectful treatment experienced by some women;
- Significant psychological trauma suffered by many families;
- Failures to properly investigate incidents and learn from mistakes or potentially cover up bad outcomes;
- Ineffective compliance with governance procedures and frameworks;
- Leadership and cultural issues which allowed unsafe practices to continue.
These issues were not isolated incidents but reflected deeper systemic problems that persisted over many years.
What Is the Report Recommending?
The review sets out a series of urgent actions that should be implemented both locally and nationally. The core themes of these recommendations are that:
- Women Must Be Heard – women and families must be listened to when they raise concerns and those concerns must be taken seriously and acted upon promptly.
- Better Communication and Shared Decision-Making – women and families should be placed at the centre of all decisions about their care.
- National Standards for Escalation and Safety – there should be national standardisation of assessment, monitoring and escalation processes so that safety concerns are recognised and acted upon consistently across all maternity services.
- Addressing Staffing Shortages – inadequate staffing being one of the most significant factors contributing to poor outcomes, there must be proper funding in place to provide sufficient staff and protect time for completing essential training.
- Learning From Mistakes – greater transparency, accountability and a culture that encourages staff to speak up about concerns.
- Stronger Leadership and Accountability – greater oversight, improved governance and a renewed focus on professional standards.
- Tackling Inequality in Maternity Care – the review highlighted concerns raised by women from Black, Asian and other minority ethnic backgrounds, who reported experiences of stereotyping and cultural misunderstanding. Maternity care must be safe, equitable and accessible for all women, regardless of their background.
Moving Forward
For many families who have had a difficult and traumatic experience with maternity services, understanding what happened and obtaining answers can be an important part of moving forward. Often there is no way to fully compensate the lasting effect of those experiences.
Clinical negligence claims can help uncover the circumstances surrounding a serious incident and secure access to specialist support and treatment so that the best recovery from that trauma can be achieved.