Hundreds of babies and mothers died following "systemic" failings at a UK hospital trust, according to the findings of a major review. The investigation, led by Donna Ockenden, also identified a "bullying and toxic culture" within the maternity services.
The review, which began in 2022, gathered input from approximately 2,500 families and over 800 staff members. However, Ockenden noted "gaps" in the information, as some senior leaders declined to participate.
Experts involved in the review analyzed 444 maternity cases and 76 neonatal cases up to May 2025. They concluded that there were "potentially avoidable" adverse outcomes in all 520 cases examined. These cases were categorized by the level of harm, with grade two indicating sub-optimal care where different management might have altered the outcome, and grade three signifying "significant" or "major concerns" where different management would reasonably be expected to have made a difference.
In response to the findings and the refusal of some management to engage with the review, the government announced an extension of "Martha's Rule" to enhance accountability and safety for mothers and babies. Measures are also being introduced to compel NHS staff, both past and present, to provide evidence for upcoming maternity reviews, with potential imprisonment of up to two years for non-compliance, though enforcement mechanisms are still being clarified.