The Ockenden Review into maternity services
The Ockenden Review into maternity services at Nottingham University Hospitals NHS Trust was published last week. The final report identified ‘long-standing and deeply embedded systemic failures’ which led to the avoidable harm and deaths of hundreds of mothers and babies.
Nearly 2,500 families contributed to the inquiry; they each experienced loss, damage or harm during pregnancy, childbirth and the early postnatal period between 2012 and 2025. Overall, the report found that there were 444 maternity and 76 neonatal cases that suffered ‘potentially avoidable outcomes’ due to failings in care.
The review, led by senior midwife Donna Ockenden, attributed the harm to a range of factors rather than one single failing. Affected women reported experiencing ‘a loss of autonomy, inadequate communication, poor emotional and psychological safety, understaffing, delayed or missing observations, and failures in escalation’. The report noted that these issues had been present in the Trust for more than a decade, indicating that the ‘challenges were deeply embedded and not limited to individual staff members, isolated events, or short-term operational pressures.’
Ockenden also highlighted how workplace culture and suboptimal leadership shaped the care provided to patients. The review identified a long-standing ‘bullying and toxic culture’, with 40% of staff regularly witnessing or experiencing this behaviour. This attitude inevitably had a negative impact on the patient experience, with many families reporting unsympathetic and unsupportive labour care. One distressed woman was even told “you need to pull yourself together.”
The report identified recurring failings in clinical care including missed or delayed observations, poor fetal monitoring and failure to escalate concerns. Ockenden therefore urged the Secretary of State for Health and Social Care to take immediate action, noting that excellent healthcare requires ‘empathetic leadership, individualised care, and an unwavering commitment to systemic equity’.
We sincerely hope that this review will lead to vital systemic change so that no more women and babies endure avoidable harm during childbirth. The inquiry would not have been possible without the contributions from the families who have been affected. Our thoughts remain with them.
Sources:
