The Ockenden Report: Nottingham must be the catalyst for lasting change in maternity care

The release of Donna Ockenden’s review into maternity services at Nottingham University Hospitals NHS Trust (the Nottingham Trust) highlights yet another serious failure in NHS maternity care. For the thousands of affected families, this report reflects years of campaigning, grief, unanswered questions, and a determined effort to have their experiences formally recognised.

As a solicitor specialising in obstetric negligence, I have supported many families whose lives have been profoundly changed. We must not forget that every statistic represents a mother who was not heard, a baby who should have come home, parents facing unimaginable loss, and a family left questioning whether a different outcome was possible if concerns had been addressed.

The findings from Nottingham are deeply distressing, yet they are also painfully familiar.

Donna Ockenden’s independent review examined approximately 2,500 cases involving mothers and babies under the care of the Nottingham Trust between 2012 and 2025, making it the largest maternity review in NHS history.

The report concluded that 444 women and 76 babies suffered potentially avoidable harm as a result of substandard maternity care. It also identified failures in care that may have contributed to, or substantially impacted, six maternal deaths.

The review identified recurring issues, including:

• women not being heard when raising concerns;
• repeated misinterpretation of CTG traces;
• delays in escalating issues to senior clinicians;
• inadequate monitoring of babies during labour;
• persistent staffing shortages; and
• a workplace culture marked by bullying and defensiveness.

The report noted that concerns were raised repeatedly over many years, but meaningful action was not taken.

The full review can be accessed via the Independent Maternity Review website.

For me, one of the most notable aspects of the Nottingham review is that its findings were unsurprising to the families involved.

Parents spent years seeking recognition of their experiences, with many challenging internal investigations that found no fault, whilst others pursued external reviews after feeling dismissed by the organisations responsible for their care.

The emotional burden on these families is immense. Trauma and grief are challenging enough without also having to act as investigators, campaigners, and advocates to seek the truth.

As a lawyer supporting families affected by birth and maternity injuries, I often witness how exhausting this process is. Clients frequently tell me their main motivation is not financial compensation. They want answers, accountability, and, most of all, assurance that lessons will be learned to prevent others from experiencing similar pain.

It would be more reassuring if Nottingham were an isolated case, but the evidence indicates the contrary. This review follows similar investigations into serious maternity failings at Morecambe Bay, East Kent, and Shrewsbury and Telford. Across these inquiries, repeated themes have emerged: poor communication, failures to escalate concerns, inadequate staffing, and cultures resistant to challenge.

This pattern of repetition is cause for major concern.

Pregnancy and childbirth are not illnesses, and most families receive safe, positive care. However, maternity services must be prepared to identify complications and respond promptly, compassionately, and effectively.

When systems repeatedly fail in similar ways, it raises questions about whether recommendations are leading to lasting improvements.

One of the strongest messages to emerge from the Nottingham report is the importance of listening to women.

Concerns raised by mothers were often minimised, dismissed, or attributed to anxiety, with many women feeling ignored when reporting reduced foetal movements, worsening symptoms, or fears that something was wrong.

This is not only a matter of bedside manner – careful listening is essential for safe clinical practice.

NHS England’s guidance on reducing stillbirth and neonatal death has long stressed the need to respond appropriately to concerns about foetal movements and maternal wellbeing. However, the Nottingham review found missed opportunities to intervene.

Information about safer maternity care initiatives can be found through NHS England.

For families, these findings may resonate deeply, as feeling unheard during pregnancy or labour can compound trauma long after the event itself.

Following publication of the report, the Health Secretary, James Murray, pledged that its recommendations would not “sit on a shelf”. But families have heard similar assurances before.

Commitments to strengthen accountability and give patients greater opportunities to escalate concerns are welcome. However, scepticism remains among those who have seen past recommendations lose momentum after media attention fades. The true test of this report is not the language used in response, but whether it leads to measurable, transparent, and lasting improvements.

This will require leadership that addresses difficult issues, sufficient investment in maternity services, and a culture where staff can raise concerns without fear.

It also requires listening to families whose experiences have revealed these failings. When healthcare systems fail to listen willingly, the legal framework often becomes the only mechanism left for families to force a meaningful response.

No legal claim can undo the loss of a child or erase the trauma associated with avoidable harm. However, for many families, the legal process is less about financial compensation and more about uncovering the truth.

When internal hospital investigations minimise or dismiss errors, a legal claim provides a vital route to an independent, objective investigation. It offers a structured way to resolve unanswered questions, secure crucial financial support for a child’s future, and obtain formal acknowledgement of what went wrong and ensure lessons cannot easily be ignored.

If you believe negligent maternity care contributed to your experience, seeking specialist advice can help you understand what happened and determine if further investigation is needed.

Equally important is recognising that support extends beyond a claim. Families affected by traumatic births, avoidable harm, or the loss of a baby often benefit from connecting with organisations that provide information, practical guidance, and peer support from others who truly understand their experiences.

Support and further information are available from organisations including MASIC, which supports women living with severe birth injuries following childbirth; the Birth Trauma Association, which provides support to parents experiencing post-traumatic stress after birth; and Make Birth Better, a charity dedicated to improving the care and support available to those affected by birth trauma.

Our Maternal Injury Guide also sets out the support available to families following birth trauma.

In addition, RWK Goodman shares information and resources through its maternal and birth injury Instagram communities, including What About Mums and Little Champions, which aim to raise awareness and support conversations around maternal wellbeing and children’s injuries.

Find out more about our expertise in supporting families affected by birth injuries.

Families affected by serious maternity incidents may encounter the Maternity and Newborn Safety Investigations (MNSI) programme, which undertakes independent safety investigations into certain maternity events.

The purpose of these investigations is to identify opportunities for learning and improvement rather than attribute blame. Understanding how the process works can be invaluable during an already overwhelming time.

You can also read our guide to what families need to know about MNSI investigations.

The Nottingham families have shown remarkable courage. By sharing their most painful experiences, they have helped expose failings that may have otherwise remained hidden, hoping to make care safer for future mothers and babies.

The Ockenden Report highlights a system that failed to respond promptly to warning signs, but it also offers an opportunity to learn and improve. If healthcare leaders act decisively, implement recommendations transparently, and prioritise the experiences of women and families, Nottingham could drive meaningful national change in maternity care. If not, future families will continue to suffer the consequences of lessons the NHS has already been forced to learn far too many times.

For further reflection on the wider national conversation around maternity safety, you may also wish to read our previous article, “The Birth Trauma Inquiry report: one year on“.