A comprehensive review into maternity care at Nottingham University Hospitals NHS Trust has revealed a decade of severe failings, resulting in the deaths of 156 infants and six mothers. Hundreds more women and babies suffered serious, long-term injuries, including brain damage, according to the report led by senior midwife Donna Ockenden.
The report, which gathered evidence from 2,500 families, highlighted a pervasive pattern of mothers' concerns being dismissed, minimized, or disbelieved. These failures have left many women traumatized and suffering from post-traumatic stress disorder (PTSD).
Systemic Failures and Tragic Consequences
Details from the report paint a grim picture of substandard care, including instances where women's pleas for pain relief went unanswered, and they were left to give birth alone. Many were turned away when seeking help for early or advanced labor, or when raising concerns about their baby's movement or growth, often being told they were being overly anxious. Requests for caesarean sections were frequently denied, even when concerns were significant, with a continued focus on achieving “normal births” leading to tragic outcomes.
The review identified several key areas of failure: poor risk assessments, delays in examining women during labor and escalating concerns, inappropriate use of oxytocin for induction, and delays in responding to postpartum hemorrhages. Inadequate support was provided for women whose first language was not English, and postnatal mothers experiencing deterioration were not properly assessed. Managers were often described as "invisible, unapproachable and unresponsive," contributing to poor governance and a "culture of organizational denial" where poor outcomes were routinely dismissed.
Staff shortages and operational pressures meant that staff were frequently working beyond safe capacity. A "bullying and toxic culture" was reported among some staff, particularly on labor wards.
Appalling Incidents and Betrayed Trust
Shocking accounts detailed in the report include instances of staff allegedly laughing about a miscarriage and one midwife instructing a partner to silence a screaming woman. Other women reported being sneered at for requesting pain relief, with emergency buzzers going unanswered and some women forced to call the hospital switchboard for assistance. Reports also emerged of patients being left without food and water for extended periods on dirty wards.
The mistreatment extended even after death. In some cases, infants were disposed of as "clinical waste," and one baby was placed in a mortuary space already occupied by an unrelated adult. One family received graphic post-mortem photographs of their deceased child by mistake. In another disturbing incident, the body of a mother who died in childbirth in July 2021 deteriorated due to incorrect storage, preventing her family from viewing her to say goodbye.
Families' Long Fight for Accountability
The report's publication marks the culmination of a ten-year campaign by Jack and Sarah Hawkins, whose daughter Harriet died in 2016 due to "significant failings" in maternity care. Despite their repeated concerns and visits to the maternity unit during a prolonged labor, they were consistently told to stay home. When Harriet was eventually delivered stillborn, the trust initially attributed her death to an infection and advised the couple to "try to move on." However, Dr. Hawkins, an infections expert, challenged this, and an external inquiry later found 13 failings, stating Harriet's death was "almost certainly preventable."
Gary and Sarah Andrews were also affected by the failings; their daughter Wynter died just 23 minutes after birth. The trust was fined £800,000 in 2023 after admitting failings in Wynter's care. Emily Stringer's daughter Caitlin suffered severe brain injury at birth in December 2021, leaving her with ongoing medical challenges. Despite Ms. Stringer, a midwife herself, raising concerns about her baby's deteriorating condition, staff dismissed her worries, suggesting mental health issues and delaying critical antibiotics for nearly 18 hours, by which time Caitlin had collapsed.
Emmie Studencki and Ryan Parker lost their son Quinn in July 2021 after multiple visits to the hospital for bleeding were dismissed. Despite a doctor recognizing the need for an emergency C-section, a midwife reportedly advised Ms. Studencki to go for a walk. Quinn was born via emergency C-section and died two days later. The trust was fined £1.6 million for avoidable harm in this and two other cases.
Introduction of "Martha's Rule" to Maternity Units
In response to these ongoing concerns about patient safety and the need for timely medical intervention, "Martha's Rule" will be extended to all maternity units in England. This initiative provides families with formal 24/7 access to a rapid review of care by a senior clinician if they believe a mother or baby's condition is deteriorating and staff are not responding adequately. The measure is named after 13-year-old Martha Mills, who died from sepsis in 2021 after her transfer to intensive care was delayed. Health Secretary James Murray stated that the review highlights a culture where voices went unheard and opportunities to prevent harm were missed, emphasizing the need for swift action.
The families of Nottingham have called for transparency and accountability, emphasizing that apologies are insufficient and a full confession of wrongdoing is needed to ensure such tragedies are not repeated.