A major independent review into the largest maternity care scandal in NHS history has revealed that more than 500 mothers and babies died or were seriously harmed due to systemic failures at Nottingham University Hospitals NHS Trust between 2012 and 2025. The review, led by senior midwife Donna Ockenden, examined 2,500 cases involving stillbirths, maternal deaths, and severe injuries, concluding that a significant number of these tragedies could have been avoided with adequate care.
Systemic Failures Across All Stages of Care
The report found that failures in maternity and neonatal care were 'systemic, deep-rooted and sustained over many years.' At every stage—from antenatal to postnatal—mothers and babies were subjected to repeated failures to accurately report, grade, and investigate serious incidents. These incidents were often downgraded or dismissed as 'unavoidable' to protect the trust's reputation, leading to severe harm or death.
Of the 462 stillbirths reviewed, about one in five case reviews of mothers were graded 2 or 3, indicating significant or major concerns in care. Similarly, of the 27 maternal deaths reviewed, suboptimal care was identified in approximately one-fifth (21.4%) of cases. The review also documented severe complications among mothers: 142 cases of fourth-degree perineal tears, 130 unexpected admissions to intensive care (ITU), 115 cases of massive obstetric haemorrhage, and 76 cases of severe pre-eclampsia. More than a third (35.6%) of mothers admitted to ITU received care graded as suboptimal.
Women's Concerns Consistently Ignored
Women repeatedly reported feeling dismissed, disempowered, or blamed when they expressed anxiety or reported critical symptoms such as reduced foetal movements, severe pain, hypertension, or postnatal deterioration. Their instincts and physical concerns were frequently minimised, normalised, or reframed as maternal anxiety. One woman described being 'sneered at for asking for pain relief,' while another was told, 'If you don't like it, you should have gone somewhere else.'
A key example involved the case of baby Harriet Hawkins, who was stillborn. Despite her mother, Sarah Hawkins, making repeated phone calls about intense, continuous pain and contractions, her symptoms were ignored and dismissed. Hawkins and her partner received £2.8 million in a clinical negligence settlement from the trust—the largest payout ever for stillbirth clinical negligence.
Chronic Understaffing and Toxic Workplace Culture
Chronic understaffing was identified as 'one of the most pervasive themes,' with women describing an environment where midwives and doctors were overstretched, exhausted, and unable to respond promptly. A toxic culture of bullying among staff persisted over the decade, severely affecting both staff wellbeing and patient safety. Staff described a normalised culture of hierarchy, nepotism, and aggressive behaviour, particularly from labour ward coordinators.
Examples included coordinators writing terms like 'idiot' on the board instead of midwives' names, sending threatening letters, and throwing urine over a staff member's car without effective HR intervention. One staff member stated: 'In a harsh working environment you survive by becoming hard; the bullying culture is a way of managing your anxiety.'
Staffing shortages affected all disciplines: 80% of surveyed staff said there were not enough personnel for the workload, and 59% regularly worked beyond rostered hours. In neonatal intensive care units, nurses reported being assigned up to nine babies at once.
Health Inequalities Exacerbated Poor Care
Failures to listen to women were even more pronounced for those from Black, Asian, and other ethnic backgrounds, as well as teenage mothers and those from deprived backgrounds. Mothers from minority backgrounds reported direct racism and a 'toxic blame culture' where they were stereotyped and judged negatively if perceived as 'loud' or 'too demanding.' Staff noted that mothers from Traveller/Gypsy/Roma backgrounds were treated 'particularly appallingly.'
In one case, a woman from a north African background reported persistent headaches, slurred speech, and facial asymmetry, but staff wrongly attributed her symptoms to 'hormones' and ignored her family's pleas; she later died from a brain tumour. In another, a woman's headaches, confusion, and incontinence were inappropriately attributed to mental health concerns and a 'language barrier'; she also later died from a brain tumour.
Psychological Harm and Failures in Post-Death Care
The review uncovered severe systemic failings in mortuary and post-death care, including the disposal of an early gestation baby as clinical waste, a deceased baby kept in a domestic fridge instead of a mortuary, and placing a baby on a storage tray with an unrelated adult. Families described a lack of compassionate bereavement care, poor communication about postmortem results, and inappropriate mortuary environments.
The trauma caused by poor experiences led some mothers to end subsequent pregnancies. One mother, 'desperate to have any children,' discovered she was pregnant with her second child and sought a termination because she was 'too frightened to go through the experience again.' Another mother diagnosed with post-traumatic stress disorder said: 'We haven't had any more children, and that is why we haven't had any more children, and I just don't want to go through that again.'
