An independent report has exposed the largest maternity scandal in the history of Britain's National Health Service (NHS), revealing that hundreds of mothers and babies died or suffered potentially avoidable harm at Nottingham University Hospitals NHS Trust (NUH). The review, which analyzed 2,500 cases over four years, found 520 instances of poor care that resulted in death or serious injury.
The 343-page report, led by expert midwife Donna Ockenden, detailed a 'toxic culture' within the trust where 'speaking up was dangerous' and the responses of bosses were 'shaped by self protection rather than patient safety.' Families who raised complaints about care were reportedly met with an 'intimidating, male-dominated' panel that was 'dismissive of non-medical voices.'
According to the report, babies died from conditions including oxygen starvation, mismanaged labor, hospital-acquired infections, and inadequate postnatal care. Others sustained serious and life-long injuries. The review found that women in severe pain were sometimes turned away, while others were treated with excessive force. 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.'
Some staff who worked at NUH before 2017 described trust managers as 'invisible, unapproachable and unresponsive,' and alleged that concerns were ignored, and bullying was prevalent. The report noted that some managers refused to provide evidence to the review, which Ockenden suggested indicated self-preservation over patient safety.
The report highlighted that issues were known as far back as 2010, but concerns were reportedly "brushed under the carpet." Families often learned the full extent of the issues years later, sometimes only after instructing lawyers. The report also noted a "tragic quest for a normal birth" that may have prevented staff from intervening when complications arose, even when women requested Cesarean sections.
Health Secretary James Murray apologized on behalf of the NHS and stated that "no options are off the table" regarding a potential public inquiry into NUH, which could compel leaders to give evidence. The NUH trust, which operates the Queen's Medical Centre and Nottingham City Hospital, has already incurred significant costs through compensation payouts and fines.
While the Ockenden review does not name specific officials, it identifies key figures during the trust's troubled years. Dr. Peter Homa served as chief executive from 2006 to 2017. A Care Quality Commission inspection in November 2013 identified NUH as 'high risk.' Dr. Keith Girling was appointed medical director in June 2017. Eric Morton chaired the trust from May 2017 to February 2022, facing calls to resign after a critical CQC report in October 2021. Tracy Taylor became chief executive in October 2017 and left in October 2021, during which time maternity services were rated 'inadequate' by the CQC.
Jenny Leggott was involved in the merger that formed NUH in 2006 and remained with the trust until at least 2014. Joy Payne, formerly head of midwifery at Heartlands Hospital, was approached by NUH about a director of midwifery post following a review into a baby's death, a situation the family described as "smacking of a cover-up."