Donna Ockenden’s report on maternity services at Nottingham University hospitals NHS trust (NUH), between 2012 and 2025, shows that 444 women and 76 newborn babies suffered “potentially avoidable” outcomes.
The report painted a stark picture of maternity care at NUH’s two hospitals, Queen’s Medical Centre and Nottingham City Hospital.
It stated that 520 mothers and babies suffered ‘potentially avoidable’ harm or died.
Many women experienced dangerously poor and sometimes “cruel” care, and understaffing was routine.
The report lays bare a host of recurring failings in clinical care that put mothers and babies at risk and, in some cases, had catastrophic consequences.
Health secretary James Murray said the nature and scale of the failings exposed by the report were “horrific” and “chilling”.
He said he was 'heartbroken' to read Ockenden’s 401-page account of the “neglect, incompetence, racism, discrimination, contempt and harassment that so many suffered”.
The Nottingham Maternity Families group, which represents about 600 harmed and bereaved families, had called for a statutory public inquiry to investigate failings in maternity and neonatal care across the entire NHS.
Ockenden and her team of maternity experts investigated the deaths of 27 mothers between 2006 and 2024 and “identified failures in care that may have or substantially impacted on the outcome in six deaths”.
Sajid Javid, the then health secretary, ordered the review in 2022 after families warned that maternity care at NUH care was unsafe.
Martha's Rule
The government has decided to roll out Martha's Rule, a patient safety measure to all maternity settings in England.
It will ensure that every parent can request a rapid review from an independent medical team if a baby's or mother’s condition is deteriorating and not getting prompt care.
The scheme has been rolled out for inpatients in every acute hospital in England, and it has been piloted in 15 maternity and neonatal settings, with rollout to more expected this year.
The safety initiative is named after Martha Mills, who died in 2021 aged 13 after developing sepsis in hospital, where she had been admitted with a pancreatic injury after falling off her bike.
Martha’s family’s concerns about her deteriorating condition were not addressed, and in 2022, a coroner ruled that Martha would probably have survived had she been moved to intensive care earlier.
