A decade-long review into maternity care at Nottingham Universities Hospital NHS Trust has uncovered what is being called the biggest maternity scandal in the history of the UK's National Health Service (NHS). The independent report, led by senior midwife Donna Ockenden, detailed systemic failures that resulted in the deaths of 156 babies and six mothers. Hundreds more individuals suffered serious, long-term injuries, including brain damage, due to substandard care.
The report, which drew upon the experiences of 2,500 families, highlighted a persistent pattern of women's concerns being dismissed, minimized, or ignored. Many mothers reported being left traumatized and suffering from Post-Traumatic Stress Disorder (PTSD) after their pleas for help went unanswered. Accounts reveal instances where women begged for pain relief that was never administered, were turned away when seeking help for labor, or were denied requests for cesarean sections despite significant concerns about their babies' well-being.
"The quest for normal birth continued" even when serious concerns arose, leading to tragic consequences, according to Ms. Ockenden. The review exposed failures in neonatal care, an unstable leadership contributing to poor safety, and a "bullying and toxic culture" among some staff. A "culture of organisational denial" meant poor outcomes were regularly dismissed, while delays in examining women in labor and a reluctance to escalate concerns were common. Inappropriate use of oxytocin for labor induction, poor telephone risk assessments, and delays in responding to postpartum hemorrhages were also identified.
Family accounts detailed harrowing experiences, including staff allegedly laughing at a miscarriage and a midwife telling a distressed partner to quiet his wife. Some women reported being sneered at when asking for pain relief or found that call buzzers went unanswered, forcing them to seek help through the hospital switchboard. Instances of being left without food and water on wards were also reported.
The failures extended to the handling of deceased infants and mothers. One baby was placed in a mortuary with an unknown adult, while another was disposed of as "clinical waste." One family received graphic post-mortem photographs of their deceased child by mistake, and the body of a mother who died in childbirth had deteriorated so much due to incorrect storage that her family could not view her to say goodbye.
The report's findings come after a ten-year campaign by Jack and Sarah Hawkins, whose daughter Harriet died in 2016 following "significant failings" in her care. Despite being considered low-risk, Mrs. Hawkins was told to stay home and relax for days despite concerns about reduced fetal movement. When admitted on her sixth day of labor, Harriet's heartbeat could not be found, and she was delivered stillborn. The trust initially attributed Harriet's death to infection and advised the couple to "try to move on." Dr. Hawkins, an infections expert, challenged the findings, and an external inquiry later identified 13 failings, stating Harriet's death was "almost certainly preventable."
Other families shared similar devastating experiences. Gary and Sarah Andrews' daughter Wynter died just 23 minutes after birth due to failings for which NUH was fined £800,000 in 2023. Emily Stringer's daughter Caitlin suffered a severe brain injury at birth, leading to a diagnosis that she will not survive beyond childhood. Despite Ms. Stringer, a midwife herself, raising concerns about signs of a serious infection, staff dismissed her worries, suggesting she needed mental health support. Caitlin eventually received antibiotics 18 hours late, by which time she had collapsed and required surgery to remove half her bowel.
Emmie Studencki and Ryan Parker lost their son Quinn, who died two days after birth due to placental abruption and a massive hemorrhage. Despite multiple visits and significant blood loss, Ms. Studencki was sent home and her ambulance notes were lost. A request for a cesarean was denied, and despite signs of fetal distress, a midwife advised her to go for a walk instead of proceeding with an emergency C-section. NUH was previously fined £1.6 million for avoidable harm in Quinn's case and two others.
In response to the report's findings, a policy known as "Martha's Rule," which grants families 24/7 access to a rapid review of care by a second clinical team, is being extended to all maternity units in England. This initiative was developed following the death of 13-year-old Martha Mills. Health Secretary James Murray stated that the 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."
