Nottingham Maternity Review Reveals Systemic Failures and Toxic Hospital Culture

A comprehensive review led by senior midwife Donna Ockenden has uncovered deep systemic failures at Nottingham University Hospitals (NUH) NHS Trust, resulting in potentially avoidable harm or death for over 500 mothers and babies. The inquiry, the largest of its kind in NHS history, examined cases from April 2012 to May 2025 across maternity units at the Queen's Medical Centre and Nottingham City Hospital.

Experts concluded that 444 maternity cases and 76 neonatal cases involved potentially avoidable outcomes. Specifically, 260 babies were either harmed or died due to substandard care, with 155 deaths and 105 serious injuries, including permanent brain damage. The report identified critical failures in fetal heart monitoring, a lack of recognition of fetal distress during labor, and a failure to escalate urgent cases to senior medical staff.

Beyond clinical failings, the review highlighted a "bullying and toxic culture" within the trust. The report described the existence of intimidating cliques that were well known to the organization but remained unaddressed. Trust leaders were criticized for knowing about serious issues as far back as 2010 but failing to take the necessary action to prevent further tragedies.

Families have shared harrowing accounts of their experiences. Jack and Sarah Hawkins, whose daughter Harriet was stillborn in 2016, fought for years to uncover the truth after an initial internal review claimed there were no errors. Similarly, Gary and Sarah Andrews saw their daughter Wynter die in 2019; the trust was later fined £800,000 after admitting to failings in their care.

The review also exposed significant failures in post-death care. The report cited a loss of dignity for deceased infants, poor mortuary processes, and inappropriate communication with bereaved families, which caused long-term trauma.

In the wake of these findings, regulatory bodies are taking action. The Nursing and Midwifery Council is reviewing 96 fitness to practise cases, while the General Medical Council is examining 62 cases and over 300 information reports. Additionally, Nottinghamshire Police launched a manslaughter case in June 2025 as part of a wider criminal investigation known as Operation Perth.

To address these failings, the review outlines several mandatory actions for NUH. These include strengthening escalation protocols, improving neonatal care to better identify serious illness, and standardizing emergency care for conditions such as postpartum haemorrhage.