A damning three-year review into maternity care at Nottingham University Hospitals NHS Trust (NUH) has concluded that 444 women and 76 newborn babies suffered 'potentially avoidable' harm or death, sparking calls for a public inquiry into maternity services across England. Health Secretary James Murray described the findings as 'horrific' and 'chilling', stating that families endured 'dangerously and tragically deficient care at almost every turn'.
Scope of Failings
The review, led by maternity safety expert Donna Ockenden, examined cases from 2012 to 2025 at NUH's two hospitals: Queen's Medical Centre and Nottingham City Hospital. It uncovered a 'bullying and toxic culture', chronic understaffing, and a failure to learn from patient safety incidents. Ockenden reported that staff sometimes displayed 'cruel' behaviour, with women being dismissed or denied pain relief. One woman recounted being told: 'Is this your first baby? Take some paracetamol and have a hot bath.'
Maternal and Neonatal Deaths
The review investigated 27 maternal deaths between 2006 and 2024, identifying failures in care that 'may have or substantially impacted on the outcome in six deaths'. Detailed examinations of 31 newborn deaths concluded that inadequate care likely contributed to their harm. Common failures included poor monitoring during labour, misinterpretation of CTG traces, and delays in escalating concerns. In one tragic case, a baby girl who died early in gestation was 'inadvertently disposed of as clinical waste' after a postmortem examination.
Call for Public Inquiry
The Nottingham Maternity Families group, representing around 600 families, has asked Prime Minister Keir Starmer to establish a statutory public inquiry into maternity and neonatal care across the NHS. Murray said the government is considering the request, noting that 'some want a public inquiry, others take a different view', but all families seek accountability and change.
Non-Cooperation by Senior Staff
Almost half of the 66 current and former NUH executives contacted by the review did not participate, despite multiple requests. Among leaders from NHS clinical commissioning groups and integrated care boards, only four of 14 engaged. Ockenden described the trust as 'dysfunctional' and determined to hide the truth. The families called for those who refused to cooperate to be sacked, stating: 'Your failure to engage constructively... is further proof you are unfit to keep mothers and babies safe.'
Government Response
Murray announced that Martha's rule, which gives patients the right to an independent second opinion, will be implemented at every maternity unit in England. Additionally, current or past NHS staff who refuse to give evidence to maternity inquiries could face up to two years in jail. Ockenden is already leading similar reviews in Leeds and Sussex. NUH Chief Executive Anthony May and Chair Nick Carver issued an unreserved apology, saying: 'We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress.'
