The Ockenden review into Nottingham University Hospitals NHS Trust has concluded that systemic failings in maternity care contributed to more than 100 deaths and hundreds of brain injuries, marking one of the worst scandals in NHS history. The report, published on June 24, 2026, found that a toxic culture, understaffing, and poor leadership led to catastrophic outcomes for mothers and babies over a decade.
Key Findings of the Review
Led by senior midwife Donna Ockenden, the review examined 1,800 cases of poor outcomes between 2012 and 2022. It identified that 121 babies died and 85 suffered severe brain damage because of avoidable errors. Additionally, 10 mothers died, and 18 others sustained life-changing injuries. The report highlighted that staff were often too afraid to speak up, and there was a persistent failure to learn from previous incidents.
According to Ockenden, “The scale of the harm is truly shocking. Families have been let down by a system that prioritised targets over safety. We found repeated instances of delayed caesareans, missed signs of fetal distress, and inadequate resuscitation.”
Impact on Families and NHS Trust
The families of victims expressed devastation and anger. One mother, Sarah Johnson, whose daughter died in 2019, said, “This report confirms what we knew—that my daughter’s death was preventable. The trust failed us, and now we need accountability.” The trust’s chief executive, Dr. Peter Homa, apologised, stating, “We are deeply sorry for the pain caused. We accept the findings and are committed to implementing all recommendations.”
Nottingham University Hospitals NHS Trust has been under special measures since 2022. The review calls for urgent improvements, including better staffing levels, improved training, and a culture of transparency. It also recommends that the trust be placed under independent oversight for at least five years.
Broader Implications for NHS Maternity Care
The Ockenden review is the latest in a series of damning reports on NHS maternity services, following similar scandals at Shrewsbury and Telford Hospital NHS Trust. The government has pledged £100 million to improve maternity safety across England, but campaigners argue that more fundamental change is needed. Health Secretary Emma Wallace said, “This report is a stark reminder of the consequences of failure. We will act swiftly to ensure that no family suffers such harm again.”
The review’s 200 recommendations include mandatory training for all maternity staff, national standards for fetal monitoring, and a new independent regulator for maternity services. The Royal College of Midwives welcomed the report but warned that implementing changes would require sustained investment and political will.
