The chief executive of Nottingham University Hospitals (NUH) NHS Trust has described himself as “shocked and upset” following the publication of a landmark review into maternity services that uncovered widespread failings linked to avoidable deaths and serious harm affecting hundreds of mothers and babies.
The independent review, led by senior midwife Donna Ockenden, has become the largest maternity investigation in NHS history. Its findings paint a deeply troubling picture of systemic failures within Nottingham’s maternity services, highlighting longstanding issues related to patient safety, leadership, accountability and workplace culture.
Following the release of the report, NUH Chief Executive Anthony May acknowledged the severity of the findings and pledged to oversee a comprehensive programme of reforms aimed at restoring public confidence and improving maternity care standards across the trust.
Largest NHS Maternity Review Reveals Widespread Failures
The review examined maternity services provided by Nottingham University Hospitals NHS Trust and included evidence from approximately 2,500 families and more than 800 current and former staff members.
The investigation concluded that deeply embedded systemic failures contributed to avoidable harm over a prolonged period. According to the review, 520 cases involved outcomes that may potentially have been avoided had appropriate care been delivered.
The findings also revealed that different clinical decisions or interventions could have altered outcomes in 260 cases involving babies. These included 155 infant deaths and 105 cases in which children suffered serious brain injuries associated with substandard maternity care.
The report identified failures across multiple aspects of maternity services, including clinical decision-making, communication, risk management and organisational oversight. It also highlighted significant shortcomings in how concerns were escalated and addressed by leadership teams.
Toxic Workplace Culture Identified
One of the most striking conclusions of the review was the existence of what was described as a “bullying and toxic” workplace culture within parts of the maternity service.
According to Donna Ockenden, some staff members felt unable to raise concerns due to fear of repercussions, creating an environment in which serious issues remained unchallenged. The review suggested that a small number of influential individuals contributed to a culture that discouraged transparency and inhibited opportunities for improvement.
Healthcare experts have long warned that workplace culture plays a critical role in patient safety, particularly in high-risk clinical environments such as maternity services. The review’s findings indicate that organisational culture was a significant factor in the persistence of unsafe practices.
Anthony May Commits to Long-Term Reform
Speaking after the publication of the report, Anthony May described the findings as both deeply upsetting and profoundly impactful.
He said the experiences shared by families throughout the investigation reinforced the need for continued reform and expressed admiration for the determination of parents who campaigned for answers despite years of frustration and grief.
May stated that the trust accepts the findings of the review and is committed to implementing all immediate and essential actions recommended by Ockenden and her team.
He confirmed that he intends to remain in his role for at least the next two years in order to oversee the implementation of reforms and ensure that improvements become embedded across the organisation.
The chief executive described the report as a “watershed moment” for the trust and stressed that meaningful change would only be possible through continued engagement with affected families and frontline staff.
Improvements Already Underway
While acknowledging the seriousness of the findings, May noted that some reforms have already been introduced during the course of the review.
Among the measures implemented is Martha’s Rule, a patient safety initiative designed to ensure that concerns raised by patients and families receive timely clinical attention. Nottingham University Hospitals became one of the first NHS trusts to introduce the policy within maternity services.
The trust has also undertaken broader efforts to strengthen governance, improve communication pathways and enhance clinical oversight.
However, the report makes clear that substantial work remains necessary to address historical shortcomings and rebuild confidence among patients, staff and the wider public.
Families Renew Calls for Accountability
The publication of the review has prompted renewed calls from affected families for a statutory public inquiry into maternity services across England.
Many campaigners argue that while the review has uncovered significant evidence of failings, additional powers are needed to ensure full accountability. A statutory inquiry would have the authority to compel witnesses to provide evidence and disclose relevant documents.
Families affected by the scandal continue to question why warning signs were not acted upon earlier and why repeated concerns failed to trigger more decisive intervention.
David and Natalie Needham, whose son Kouper died shortly after being discharged from hospital in 2019, described the findings as both powerful and deeply shocking. They said the report reinforced concerns raised by families over many years regarding the quality and safety of maternity care.
Similarly, Felicity Benyon, who suffered severe complications during childbirth, expressed frustration that numerous warnings had been raised internally and externally without sufficient action being taken.
For many families, the central issue remains accountability and ensuring that lessons are translated into lasting improvements.
New Measures to Strengthen Participation in Future Reviews
The report also highlighted concerns regarding the participation of former senior leaders in the review process.
Of 66 current and former senior officials approached by the trust, only a portion agreed to participate in interviews conducted by the review team. Several former leaders declined to engage with the investigation.
In response to concerns about non-cooperation in future healthcare reviews, the government announced new measures linked to the expansion of Martha’s Rule. Under the proposed framework, current or former NHS employees who refuse to engage with future official investigations could face legal consequences, including potential prison sentences of up to two years.
The move reflects growing political pressure to improve transparency and accountability across the health service.
A Defining Moment for NHS Maternity Services
The Nottingham maternity review is expected to have far-reaching implications for maternity care across England. As the largest investigation of its kind in NHS history, its findings have reignited debate about patient safety, leadership accountability and the effectiveness of oversight mechanisms within healthcare organisations.
While Nottingham University Hospitals NHS Trust has committed to implementing the report’s recommendations, families and campaigners insist that meaningful change will depend not only on policy reforms but also on a fundamental shift in organisational culture.
For the thousands of families affected, the publication of the review represents an important milestone in their pursuit of answers, accountability and safer maternity services for future generations.