A comprehensive review into maternity services at Nottingham University Hospitals (NUH) NHS Trust has detailed widespread failings that led to hundreds of avoidable baby deaths, stillbirths, and severe infant brain damage between 2012 and 2025. The report, described as the largest maternity review in the history of the National Health Service (NHS), is expected to expose an 'institutional cover-up' where senior leaders allegedly concealed staff errors, downgraded reports of nurse failings, and dismissed concerns from mothers to avoid scrutiny.
Expert midwife Donna Ockenden, who led the review of more than 2,500 cases, is set to conclude that poor care significantly harmed mothers and babies. While Ockenden's team interviewed over 800 staff members, approximately half of the 60 former senior executives and directors approached declined to answer questions about their involvement.
The NHS is preparing for the release of the 350-page report, which is anticipated to trigger demands for substantial changes in maternity care across the country. In addition to patient harm, the review also notes instances of women experiencing cruel and racist treatment.
Families who have campaigned for justice have been instrumental in driving the inquiry. Among them are Jack and Sarah Hawkins, whose daughter Harriet was stillborn in 2016. Despite being initially told her death was due to infection and that no errors occurred in her care, the couple uncovered evidence of medical mistakes. Their experience was compounded by the hospital recording a conversation with Mr. Hawkins without his consent and later mocking him, and his daughter's body decomposing in the hospital mortuary for ten months. The couple was eventually awarded £2.8 million in damages.
Sarah and Gary Andrews lost their daughter Wynter 23 minutes after birth in 2019. NUH was fined £800,000 in 2023 following a criminal prosecution by the Care Quality Commission (CQC) for failings in Wynter's care. The Andrews family views the Ockenden report as a starting point for change, hoping to prevent other families from enduring similar tragedies.
Mel Ibrahim delivered her daughter Amaya alone in a bathroom at Queen's Medical Centre around 24 weeks of gestation in 2016. Amaya, born weighing just over one pound, suffered severe health complications including a brain bleed, sepsis, and chronic lung disease, resulting in cerebral palsy, autism, and profound deafness. Ms. Ibrahim has expressed lingering questions about the care provided to her and her daughter.
Laura Flanagan described a 'nightmare' scenario when her son Archie, born in January 2022, became unwell shortly after birth and required ventilation. Ms. Flanagan reported feeling ignored and dismissed by hospital staff.
The review's findings come as Nottinghamshire Police continue a corporate manslaughter investigation, codenamed Operation Perth, examining hundreds of serious injuries and deaths at NUH. Two men, aged 55 and 59, were arrested in connection with practices within the trust's mortuary service on suspicion of misconduct in a public office.
Regulators are also taking action. The Nursing and Midwifery Council (NMC) is assessing 96 fitness to practise cases related to maternity care at NUH, while the General Medical Council (GMC) is investigating 62 cases involving doctors. In a separate case last February, NUH paid £1.66 million after admitting to six charges brought by the CQC concerning failures in care for three mothers and their babies.
These events at NUH are occurring amidst broader concerns about maternity care across the UK, with more than a dozen other NHS trusts facing investigations and over two-thirds of maternity units instructed by the CQC to improve their safety standards.