The government has announced that Martha's Rule will be rolled out to all maternity settings in England, following the largest NHS maternity review in history, which found that hundreds of mothers and babies had potentially suffered avoidable harm. The review, led by senior midwife Donna Ockenden, examined care at Nottingham University Hospitals NHS Trust (NUH) and concluded that there were “potentially avoidable” outcomes relating to 444 maternity cases and 76 neonatal cases up to May 2025.
Systemic Failures and Toxic Culture
Ockenden's 400-page report identified “longstanding and deeply embedded systemic failures” and a “bullying and toxic culture” at the trust. Families “repeatedly described feeling unheard, inadequately informed and unsupported when expressing anxiety,” the report said. It found failures in monitoring babies, poor CTG interpretation, a failure to recognise distress during labour, and a failure to escalate cases to senior doctors. There was also evidence that harm was sometimes downgraded by the trust, and some families were told babies had died of natural causes when that was not true.
Martha's Rule Expansion
Martha's Rule was created after 13-year-old Martha Mills died from sepsis in 2021, after medics failed to listen to her family's concerns. The scheme, which gives patients and staff the right to request a second opinion 24/7 if they fear risk, has already been rolled out for inpatients in every acute hospital in England. It has been piloted in 15 maternity and neonatal settings, with rollout to all maternity units now confirmed.
Scale of Harm
The review classified the 444 cases as grade two or three for harm. Grade two represents sub-optimal care where different management might have made a difference; grade three is where different management would reasonably be expected to have made a difference. Overall, 31 reviews into newborn deaths and six maternal deaths were classified as grade two or three. One mother and eight babies were grade three, suggesting they should have survived with better care. Other serious cases involved mothers or babies suffering haemorrhaging, ending up in intensive care, or being left with brain damage that may have been avoidable.
Official Responses
Kate Brintworth, chief midwifery officer for England, said: “I am so sorry for the heartbreaking loss, grief and pain experienced by women and families at Nottingham. My thoughts are with those who have been harmed, bereaved or let down by the care they received. They have shown extraordinary courage in speaking up, and their voices must be at the centre of how the NHS responds.” Health Secretary James Murray said he met with families in Nottingham and heard about the “devastating loss” they suffered “often caused by horrendous care they received on the NHS.” He added: “Donna Ockenden’s review lays bare a culture where too many voices went unheard, too many opportunities to prevent harm were missed and too many lives were lost. That’s why we have to take action, and quickly.”
