Nottingham NHS Maternity Scandal: 520 Mothers and Babies Harmed

A review by maternity expert Donna Ockenden found that 520 mothers and babies suffered harm or died due to “horrific” failings at Nottingham University Hospitals NHS Trust (NUH) between 2012 and 2025. Health Secretary James Murray stated the NHS “failed them catastrophically,” prompting the nationwide implementation of “Martha’s rule” to provide patients independent second opinions.

What caused the maternity failings at NUH?

The 401-page report by Donna Ockenden concluded that 444 women and 76 newborn babies experienced “potentially avoidable” outcomes. Ockenden identified a “bullying and toxic culture” at Queen’s Medical Centre and Nottingham City Hospital that impeded improvements to care.

Clinical failures included repeated errors in monitoring babies during labor and the misinterpretation of CTG traces. Midwives often failed to escalate worrying cases to doctors urgently, according to the report. These failures contributed to neonatal death, stillbirth, and severe neonatal injury.

Ockenden also found that staff routinely ignored women’s concerns and maintained a “culture of not admitting women who were seeking admission in labour.” Understaffing was described as routine, leaving units unable to cope with birth volumes or case complexity.

Did You Know? The review process involved evidence from 2,536 families and 838 current or former NUH staff members.

How did the trust respond to the investigation?

The report described the trust as dysfunctional and determined to hide the truth. Almost half of the 66 current and former NUH executives asked to engage with the inquiry refused to do so, according to Ockenden.

Donna Ockenden warns maternity safety crisis needs immediate action

The response from other leaders was lower; only four of 14 contacted leaders from the NHS clinical commissioning group and integrated care boards participated. The Nottingham Maternity Families group called this refusal “appalling” and suggested the executives be sacked.

NUH chief executive Anthony May and chair Nick Carver issued an open letter to the community. They apologized unreservedly to the families who suffered harm, loss, trauma, or distress.

Expert Insight: Samantha Carter notes that the high rate of executive non-compliance during the review suggests a systemic prioritization of self-preservation over patient safety. This “culture of silence” likely complicates the process of establishing full accountability and may hinder the implementation of the government’s proposed action plan.

What happens next for maternity care in England?

James Murray announced that “Martha’s rule” will now be implemented at every maternity unit in England. This rule grants patients the right to an independent second opinion from a separate clinical team.

To combat the “culture of silence,” the government may introduce penalties for staff who refuse to provide evidence to maternity inquiries. Such individuals could face up to two years in jail.

The government is also considering a request from the Nottingham Maternity Families group for a statutory public inquiry into neonatal and maternity care across the entire NHS. Murray stated that nothing is “off the table” regarding this possibility.

Frequently Asked Questions

How many deaths were investigated in the Ockenden report?
Ockenden and her team investigated the deaths of 27 mothers between 2006 and 2024, finding that failures in care may have substantially impacted the outcome in six of those deaths. They also examined 31 newborn deaths, concluding those infants received inadequate care.

What is Martha’s rule?
Martha’s rule gives patients the right to an independent second opinion of their care provided by a separate clinical team.

Are other hospitals being reviewed?
Yes, Donna Ockenden is currently leading reviews into what families describe as endemic failings of NHS maternity care in Sussex and Leeds.

Do you believe a national public inquiry is the most effective way to ensure accountability in healthcare?