Ockenden Review of Maternity Care at Nottingham University Hospitals Trust Published

Of interest to every healthcare practitioner and every member of the public is the review of maternity services at Nottingham University Hospitals NHS Trust, published this week.

The review, led by Donna Ockenden (an independent senior midwife) examined cases involving mothers and babies dying or being seriously injured, or babies being stillborn, while under the care of the trust.

In a review of 2,500 cases between 2012 and 2025 it was discovered that more than 500 mothers and babies died or were harmed at the ‘toxic’ trust.

The main findings of the review:

• Failures in maternity and baby care were systemic and enduring
• The concerns of women and families were ignored
• Workplace culture and staff shortages
• Pre-existing health inequalities exacerbated poor care
• Psychological harm caused by poor care and failings in post-death care

The report identified eight key headings for the immediate and essential actions which must happen:

1. Listening to Women & Families
2. Workforce Planning & Safe Staffing
3. Training & Multi‑Professional Learning
4. Risk Assessment Throughout Pregnancy
5. Incident Investigation & Family Involvement
6. Governance & Board Accountability
7. Culture, Teamwork & Psychological Safety
8. Mothers Who Have Died and Post Death Care

These are expanded upon in the review.

The full review can be accessed here.

Back to other blogs