A comprehensive review into maternity and neonatal services at Nottingham University Hospitals (NUH) NHS Trust has revealed that over 500 mothers and babies died or suffered serious harm due to "deep-rooted, systemic and sustained" failures spanning many years. The largest maternity review in NHS history, led by expert midwife Donna Ockenden, identified chronic staff shortages, inadequate management, and a lack of basic training as key contributing factors.
The report detailed a "toxic bullying culture" within the maternity units, which was allegedly perpetuated by a "small minority of powerful leaders" who mistreated both patients and staff. A "persistent" failure to listen to and believe mothers, coupled with a lack of thorough investigation and learning from mistakes, led to profound grief and pain for families experiencing death and injury during childbirth.
Over the course of the review, at least 156 baby deaths and six maternal deaths were identified. The review team found that babies died from various causes, including oxygen starvation, mismanaged labor, hospital-acquired infections, and inadequate postnatal care. The report also highlighted deeply disturbing findings regarding the handling of deceased mothers and babies, with instances of a baby being placed in a mortuary with an unrelated adult and another disposed of as clinical waste. One family received graphic post-mortem photographs of their deceased baby by mistake, while another mother's body deteriorated due to improper storage, preventing her family from viewing her.
In connection with practices at the NUH mortuary service, two men aged 55 and 59 were arrested by Nottinghamshire Police. The NUH Trust, which operates the Queen's Medical Centre and Nottingham City Hospital, has previously incurred significant costs through compensation payouts and fines following prosecutions for poor care.
A Decade of Known Failures
Donna Ockenden stated that many of the issues identified in her report have been known at NUH since at least 2010. The report documented instances where staff "laughed about a miscarriage" and where a midwife allegedly told a partner to silence a screaming woman. Other women reported being "sneered at" for requesting pain relief and experiencing unanswered calls for assistance. Staff, with 40% reporting being victims of bullying, were reportedly too afraid to speak up, and those who did were allegedly ignored.
Ms. Ockenden described the situation as a "damning indictment of Britain's sixth largest maternity service," stating that women and babies were "failed by a service which did not listen, did not learn and did not respond adequately when concerns were raised." The inquiry examined the cases of 2,500 families over more than a decade. It found instances where babies died from oxygen starvation, mismanaged labor, infections, and poor postnatal care. Failures in neonatal care were also cited as potential contributors to long-term brain injury and developmental issues.
Among the tragic cases highlighted were Harriet Hawkins, who died in 2016; Wynter Andrews, who died in 2019; and a baby referred to as Ladybird, whose parents were wrongly advised to terminate a healthy pregnancy. Overall, experts determined that "potentially avoidable" outcomes were associated with 444 maternity cases and 76 neonatal cases examined up to May 2025. These cases were graded as either "significant concerns" (Grade 2) or "major concerns" (Grade 3) regarding the care provided.
Systemic Issues and Cultural Problems
Reviewers found that in six of the 22 maternal deaths, failings in care could have led to a different outcome. Ms. Ockenden emphasized that these women were "failed by an organisation they should be able to rely upon absolutely during a period of acute vulnerability." She vowed that the report would not become "another document on a shelf" and called for it to be a catalyst for safer care and greater accountability.
She further elaborated that a toxic culture had taken hold at NUH, where "powerful leaders infected the unit," leading to an environment where bullying was normalized, speaking up was dangerous, and governance prioritized self-protection over patient safety. The incident review panel was described as intimidating and dismissive of non-medical voices. Staff reported leaving the trust due to incidents being "brushed under the carpet," and leaders were accused of prioritizing institutional reputation over patient safety.
Staffing shortages and operational pressures significantly impacted care quality and staff well-being, with many working in a state of "crisis mode." The report also noted discrimination against women from ethnic minority backgrounds and inadequate support for those whose first language was not English. Long-standing and systemic failures in clinical governance were evident, including high turnover in senior roles and inconsistent leadership.
Some patients described inadequate pain relief and dismissive attitudes from staff. Despite assurances that lessons would be learned, similar incidents recurred over many years. The report recommends immediate actions, including the rollout of Martha's Rule, to provide families with 24/7 access to a second opinion.
Investigations and Reactions
Regulators, including the General Medical Council (GMC) and Nursing and Midwifery Council (NMC), are investigating allegations against individual staff members. The NMC is reviewing 96 fitness-to-practise cases, and the GMC is examining 62 cases related to maternity care at NUH. Last February, NUH was ordered to pay £1.66 million after pleading guilty to six charges brought by the Care Quality Commission (CQC) for failing to provide safe care.
Health Secretary James Murray apologized on behalf of the NHS to the affected families, expressing being "appalled by the neglect, incompetence, racism, discrimination, contempt and harassment that so many suffered." The Chief Executive of the Royal College of Midwives, Gill Walton, stated the report exposes "more than a decade of leadership and institutional failure" and that "toxic culture, poor behaviours, bullying and racism, have no place in maternity care or the NHS."
Medical negligence lawyers and representatives from patient advocacy groups expressed devastation but noted that the findings were not surprising, echoing themes from previous maternity reviews. They emphasized the need for action, accountability, and ensuring families' voices are central to future improvements. The CEO of the Birth Trauma Association expressed concern that Nottingham's issues are not unique, citing similar findings from other reviews and urging swift implementation of recommendations nationwide.
One case detailed in the report involved Emily Stringer, a midwife herself, whose baby Caitlin suffered severe brain damage and a destroyed bowel due to delayed treatment for a dangerous infection. Despite Ms. Stringer's concerns and her professional background, staff allegedly dismissed her worries, suggesting she "stop thinking like a midwife, think like a mum." Caitlin, now four, requires constant care and is not expected to survive beyond childhood.
Sarah and Jack Hawkins, whose daughter Harriet died in 2016, were repeatedly told to stay home during labor despite concerns about reduced fetal movement. Their daughter was stillborn, and the trust initially attributed the death to an infection, later found to be inaccurate. The couple later learned staff allegedly "mocked" Dr. Hawkins after he challenged the internal investigation. In 2021, they received a £2.8 million compensation payout.
Emmie Studencki and Ryan Parker were advised against a caesarean section for suspected placental abruption, leading to a severe hemorrhage. Their son, Quinn, was born extremely unwell and died two days later. The trust was fined £1.6 million after admitting criminal charges related to avoidable harm in Quinn's case and two other cases. Ms. Studencki stated that the trust's lack of transparency has significantly worsened their grief, and they seek a confession rather than an apology.
Anthony May, CEO of NUH, acknowledged the bravery of the families and apologized for the pain and suffering endured. He stated that the trust is committed to making improvements based on the review's feedback and the staff's dedication to providing better care.