An independent report into maternity care at Nottingham University Hospitals NHS Trust has uncovered the largest maternity scandal in the history of the UK's National Health Service (NHS), finding that 520 mothers and babies suffered avoidable harm or death due to poor care. The four-year review, which analyzed 2,500 cases, detailed a "toxic culture" where bullying was normalized, speaking up was discouraged, and management prioritized self-protection over patient safety.
The report, led by midwife Donna Ockenden, found that women were often ignored when raising concerns about their care. Families who complained were frequently met with a dismissive and "male-dominated" panel that disregarded non-medical input. Ockenden stated that women were "failed by a service which did not listen, did not learn and did not respond adequately when concerns were raised."
Babies died from various causes including oxygen starvation, mishandled labor, hospital-acquired infections, and inadequate postnatal care. Others sustained serious, life-long injuries. The report noted that a misplaced pursuit of "a tragic quest for a normal birth" sometimes prevented staff from intervening appropriately, even in critical situations where mothers were requesting Cesarean sections.
Senior leaders at the trust, many of whom declined to provide evidence to the review, were accused of fostering an environment where mistakes were concealed. Staff testimonies indicated that incidents were "brushed under the carpet," and women raising concerns were told they were imagining them or were repeatedly turned away during labor.
Some families only learned the full extent of the issues years later, often after instructing lawyers. The report highlighted that although the trust knew about problems as far back as 2010, these issues were not adequately addressed.
The review identified numerous past leaders and executives who were at the helm during the period when the trust's problems escalated. These include former chief executives Peter Homa (2006-2017) and Tracy Taylor (2017-2021), medical director Keith Girling (appointed 2017), and chair Eric Morton (2017-2022). The report noted that a Care Quality Commission inspection in 2013 flagged NUH as "high risk," citing staff shortages and increasing safety problems. Despite these warnings, and subsequent critical reports and staff concerns raised between 2018 and 2021, underlying issues persisted.
In response to the report's findings, Health Secretary James Murray apologized on behalf of the NHS. He indicated that "no options are off the table" regarding potential actions, including a public inquiry that could compel leaders to provide evidence. The Nottingham University Hospitals NHS Trust, which operates the Queen's Medical Centre and Nottingham City Hospital, has already incurred significant costs through compensation payouts and fines.
Currently, 150 doctors and midwives are undergoing assessment for their fitness to practice due to complaints. The report acknowledges the significant number of senior staff who opted not to participate in the review, suggesting a prioritization of self-preservation over maternity safety.