Devastating Findings from the Ockenden Review
More than 500 mothers and babies suffered potentially avoidable harm or died because of 'deeply embedded systemic failures' at a 'toxic' hospital trust, according to a damning review led by senior midwife Donna Ockenden. The report, covering Nottingham University Hospitals NHS Trust (NUH), found that bosses knew about serious issues in the maternity department for years but failed to act, leading to further deaths.
Overall, 520 mothers and babies experienced potentially avoidable harm or death, including 94 stillborn babies. Experts found that failures in care 'may have or substantially impacted on the outcome in six deaths' of women. The review examined 444 maternity cases and 76 neonatal cases up to May 2025, all graded as 2 or 3 for harm, indicating significant or major concerns.
Key Failures in Care
The report highlighted that women and families were consistently not listened to, leading to missed opportunities to prevent harm. There were failures to recognise and escalate deterioration in babies' and mothers' health. Babies died from conditions such as oxygen starvation, mismanaged labour, hospital-acquired infections, and poor postnatal care.
Among the tragic cases were Harriet Hawkins, who died 'avoidably' in 2016; Wynter Andrews, who died in 2019; and Ladybird, whose parents were wrongly told to terminate a healthy pregnancy. The review found that at least eight neonatal deaths should have been prevented, and 30 cases of potentially avoidable harm related to massive obstetric haemorrhage.
Systemic Culture of Denial and Bullying
The report described a 'bullying and toxic culture' at the trust, with staff forming intimidating cliques that were not confronted. There was 'a culture of organisational denial' where poor outcomes were dismissed as 'known complications'. Leadership instability was a major factor, with high turnover in senior maternity positions between 2017 and 2021.
Staff reported experiences of hierarchy, bullying, nepotism, and aggressive behaviour, particularly among labour ward co-ordinators. Some women in labour faced delays in examination, and there was a reluctance to escalate concerns due to professional cultures. Inappropriate use of the drug oxytocin to induce labour was also noted.
Failures in Communication and Postnatal Care
Women repeatedly described feeling unheard and unsupported, especially regarding reduced foetal movements or medical complications. Inadequate communication support was provided for those whose first language was not English. Postnatal care failures included inadequate assessment of mothers with high blood pressure or deteriorating conditions, and failures to recognise unwell or poorly feeding babies.
Some patients received phone calls instead of in-person visits, and in several cases, the consequences of these failures were severe and irreversible. Managers were often described as 'invisible, unapproachable, and unresponsive', ignoring concerns and being rude or aggressive.
Governance and Oversight Failures
From at least 2012, there was poor governance within maternity, including serious incidents not being investigated and a failure to learn from mistakes. Staff shortages and operational pressures led to routine working beyond safe capacity. The review also found failures to protect the dignity of the deceased, including an early gestation baby disposed as clinical waste and dehumanising language by clinicians.
Nottinghamshire Police announced on Monday that two men had been arrested in connection with operating practices in the trust's mortuary service.
Reactions and Calls for Change
Donna Ockenden stated: 'We owe it to every mother, every baby and every family whose terrible experiences are recorded here that they are never repeated.' She added that 'the culture of compounding of harm needs to stop.' Clea Harmer, chief executive of Stillbirth and Neonatal Death Charity (Sands), said: 'Reading Donna Ockenden's report is absolutely heartbreaking... There is also a lot of anger and frustration.'
Health Secretary James Murray pledged to 'deliver lasting change', noting that lessons from Nottingham will form part of a national plan to improve maternal and neonatal care. The Department of Health and Social Care announced that Martha's Rule will be extended to all maternity settings in England, allowing parents to request a rapid review if concerned about deterioration.
NUH trust chairman Nick Carver and chief executive Anthony May apologised unreservedly in an open letter, acknowledging that while improvements have been made, more work is needed.
