NOTTINGHAM — A review of maternity services at Nottingham University Hospitals NHS Trust found that hundreds of mothers and babies suffered potentially avoidable harm or died due to systemic failures. Donna Ockenden chaired the inquiry into the trust's maternity services.

The Ockenden inquiry found a "persistent failure to listen to mothers and fathers." Health bosses in Nottingham were informed of a crisis in maternity services in November 2018. A letter signed by more than 50 staff at the Queen's Medical Centre warned that mistakes would be inevitable if problems were not addressed.

The November 2018 letter cited chronic understaffing, a scarcity of critical safety equipment, and a dire lack of leadership. The letter was sent to the chairman of the Nottingham University Hospitals trust, the chief executive, the medical director, and the head of midwifery. A response to the staff letter was sent two weeks later, outlining actions taken over the previous few months and offering to meet.

The 2023 review found no evidence that the board had discussed the November 2018 letter. The review stated that the response to the staff letter did not address the concerns being made. The new chief executive of the trust concluded that the response to the staff letter was unsatisfactory.

Three other maternity reviews preceded the Nottingham review in Morecambe Bay, Shrewsbury and Telford, and East Kent. There are 748 recommendations across the health service for improvements in maternity and neonatal care. A national maternity inquiry chaired by Baroness Amos was created to consolidate these recommendations into focused actions. Two further maternity inquiries have been announced in Leeds and Sussex.

The former chief executive of the Shrewsbury and Telford trust moved to a role at the Nottingham trust months after the Shrewsbury and Telford trust was placed into special measures. The government has promised that NHS staff who refuse to engage with upcoming maternity reviews will face up to two years in prison.