More than 500 mothers and babies died or suffered potentially avoidable harm due to 'deeply embedded systemic failures' at Nottingham University Hospitals NHS Trust, according to a major inquiry. The review, led by senior midwife Donna Ockenden, found that trust leaders were aware of serious issues in the maternity department for years but failed to act, resulting in preventable deaths and injuries.
Scale of Harm
The inquiry identified 520 cases of potentially avoidable harm, including at least 156 baby deaths and six maternal deaths. Among the baby deaths, 94 were stillbirths and 62 were neonatal deaths shortly after birth. Causes included oxygen starvation, mismanaged labour, hospital-acquired infections, and poor postnatal care. Over 2,500 families and more than 800 staff contributed to the largest maternity inquiry in NHS history.
Failures in Care
Assessors found failures in monitoring babies, poor interpretation of CTG traces, failure to recognise fetal distress during labour, and lack of escalation to senior doctors. Some families who raised concerns were told lessons would be learned, yet similar incidents recurred repeatedly. Harm was sometimes downgraded by the trust, with families told babies died of natural causes when that was not true.
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.'
Specific Cases
Among the babies who died were Harriet Hawkins, who died avoidably in 2016; Wynter Andrews, who died in 2019 after significant failures; and Ladybird, whose parents were wrongly advised to terminate a healthy pregnancy. The report also examined 17 babies and one adult who died, finding failures to protect the dignity of the deceased, including a baby disposed as clinical waste and dehumanising language by clinicians.
Trust Response
Nick Carver, trust chairman, and Anthony May, chief executive, apologised unreservedly and acknowledged improvements are ongoing. Health Secretary James Murray pledged to deliver lasting change, saying lessons from Nottingham will inform a national plan to improve maternal and neonatal care.
Police Action
On Monday, Nottinghamshire Police arrested two men in connection with operating practices in the trust's mortuary service.
