NHS Maternity Failures: Nottingham Ockenden Report 2026

Jodi Newton

Nottingham maternity negligence: what the Ockenden Report means for affected families

The Independent Maternity Review into maternity services at Nottingham University Hospitals NHS Trust was published on 24 June 2026. This is more widely known as the Ockenden Report, the inquiry having been led by senior midwife Donna Ockenden. The review was opened in 2022. The multidisciplinary team included over 160 independent reviewers who met with over 2,500 families involving cases from 2012-2025 and interviewed over 800 current and former members of staff.

The findings are profoundly shocking, revealing deep-rooted failures. The report, which is over 400 pages, found that 520 mothers and babies suffered potentially avoidable harm. Of these, 162 died after receiving substandard care:

• 94 stillbirths;
• 62 neonatal deaths;
• 6 maternal deaths.

Many more babies were left with serious brain injuries, including hypoxic ischaemic encephalopathy (HIE) and cerebral palsy. In half of the HIE cases reviewed, better care could have avoided the injury.
To add to the distress of these findings, nearly half of the senior directors at the Trust refused to engage with the review.

A separate criminal investigation, Operation Perth, is being run by Nottinghamshire Police into potential offences including corporate manslaughter and gross negligence manslaughter.

18 national recommendations were made for improvements to maternity care. Importantly, “Martha’s Rule” is now to be rolled out to all maternity and neonatal settings. This is to ensure every parent can request a rapid review from an independent medical team if a baby or mother’s condition is deteriorating and they are concerned this is not being addressed.

The key recommendations from Miss Ockenden’s report were as follows:

• Establishing ways to improve communication and informed choice for women, including ensuring all Trusts listen to women and families and act appropriately and timeously on concerns.
• Government should invest in the development and implementation of a robust workforce planning tool across perinatal services, to ensure appropriate staffing levels, adequate critical care equipment and emergency cover with a heavy emphasis on midwifery and obstetrics.
• The NHS should implement a nationally-recognised Labour Ward Coordinator programme for all Band 7 midwives, with all staff caring for maternity patients receiving regular multidisciplinary training.
• All NHS Trusts must ensure women receive appropriate “safety netting”, with enhanced continuity of care for all women, particularly those with additional medical or social needs, with more specialist support for families who have suffered a maternal death.
• There should be national standards for obstetric anaesthetic record-keeping.
• Investment in clearer maternity-specific Duty of Candour guidance and a feedback framework to address delays and inconsistency in the standard of communication following investigations and a new national standard for maternity investigations.
• Ensuring sufficient time is devoted to multidisciplinary governance, review and learning. As part of this initiative, all Trusts must appoint a maternity specialist with a nationally-standardised role description.
• All post-mortems must be conducted within a mortuary. All investigations or reviews into after-death care are to include an independent post-death care specialist.

Jodi Newton, Head of Birth and Paediatric Negligence at Osbornes Law commented:

“This is the latest in a long line of similar investigations, all with common themes and the objective of achieving improvement, however maternity patients are still experiencing exceptionally poor care. The apologies and promises cannot reverse the tragedies which have fallen upon the affected patients. The loss or serious harm suffered to babies and mothers is immeasurable and when it is furthermore found that these losses may have been preventable, the grief becomes even more difficult to navigate.

Expectant mothers fear falling victim to the lottery of poor-performing maternity departments and can no longer trust the clinicians on whom they are depending to safely deliver their babies. It is a fractured system which desperately needs to be overhauled with investment in staff and systems, and to meet the ongoing issues caused by reported long-running toxic cultures known to affect maternity clinicians and leadership, as was found to be the case in Nottingham, a hospital which had already been subject to a previous investigation by the media.

Baroness Amos will deliver the full findings of her national investigation into maternity care later this month. Rather than tolerate more delays and failures to implement recommendations, the government must act on her guidance, and that of Miss Ockenden, to reduce further incidences of suffering to babies and their families, which to compound the heartbreak, is often found to have been avoidable”.

Learn more on Baroness Amos’s interim report and what it found in our article.

A troubling pattern: previous maternity reviews

The Nottingham report is the latest in a long line of similar investigations, including:
Osbornes Law has acted for families across several of these scandals and has spoken publicly about the pattern. Interviewed by Sky News and Times Radio after the Shrewsbury and Telford findings, the firm warned the problems were not isolated:

“Lessons haven’t been learned, which doesn’t help the families affected later on in the timeline. We don’t think the issues identified within that report are unique to Shrewsbury and Telford Hospital NHS Trust because we deal with many cases at other hospitals where similar things are happening on a day-to-day basis.”

Shrewsbury and Telford Hospital NHS Trust

The 2022 report which followed this review, also chaired by Miss Ockenden, considered cases over 20 years and identified 201 babies who could have survived if the trust had provided better care. There were 29 cases where babies suffered severe brain injuries and 65 cases of cerebral palsy.

Nottingham University Hospitals NHS Trust

This was a joint investigation by Channel 4 and The Independent into maternity care between 2010 and 2020. It found at least 46 babies had suffered brain damage, 19 were stillborn, and there had been 15 deaths involving mothers and babies. By the time Donna Ockenden was appointed to lead an independent review in 2022, more than £91 million in damages had already been paid to affected families. The Ockenden report followed.

Mid and South Essex NHS Foundation Trust

Maternity services at Basildon University Hospital were rated “inadequate” in 2020 after a report found six babies had been starved of oxygen, with potential associated brain injuries.

Read more in our article on poor maternity care at Basildon Hospital.

Leeds Teaching Hospitals NHS Trust

A BBC investigation earlier this year found the deaths of at least 56 babies and two mothers between 2014-2019 may have been preventable. The CQC has since demanded urgent improvements at both sites and Miss Ockenden is leading a review into the maternity services at this NHS Trust.

University Hospitals Sussex NHS Foundation Trust

Nine babies died and four mothers almost lost their lives between 2021 and 2023 following alleged poor standards of care. The families affected, most notably those who are part of the group known as Truth For Our Babies, have successfully campaigned for a public inquiry and Miss Ockenden is chairing the inquiry.

Read about one family’s experience following an avoidable stillbirth at the Trust, in a case handled by Senior Associate Nicholas Leahy. 

University Hospitals of Morecambe Bay NHS Foundation Trust

Dr Bill Kirkup chaired an inquiry in 2015 after 11 babies and 1 mother died between 2004 and 2013 following failures at Furness General Hospital. Failures included poor communication with families, a flawed organisational structures, delayed problem recognition, false regulatory reassurance and a dysfunctional culture.

How can we help?

The Ockenden Report into Nottingham University Hospitals NHS Trust is the latest in a long and deeply troubling series of maternity scandals across the NHS. Despite repeated investigations and countless recommendations, families continue to suffer avoidable harm. If you or a loved one has been affected by failings in maternity or neonatal care, Osbornes Law’s specialist medical negligence team is here to help. Contact us by:

• completing our online enquiry form;
• or calling us on 020 7485 8811