NOTTINGHAM — An inquiry into maternity care at Nottingham University Hospitals Trust (NUHT) found that more than 500 mothers and babies were harmed or died due to poor care. The report, led by Donna Ockenden, detailed that 444 women and 76 newborn babies experienced potentially avoidable outcomes over 13 years at the Trust.

The inquiry identified that multiple women encountered bullying and received poor or cruel care at Queen's Medical Centre and Nottingham City Hospital. These issues occurred alongside persistent understaffing, and the report noted that both maternity units were not equipped to manage the number of births and complex cases. Consequently, mothers in labor were routinely turned away from the units and instructed to return home.

The report described a bullying and toxic culture within NUHT. It found failures in listening to women and families, continuity of care, clinical governance, and prompt access to imaging. Failures in care were found to have substantially impacted the outcome in six deaths.

The inquiry also found that senior managers did not act when repeatedly informed about specific problems. When complaints were made, the Trust's initial response was to conceal issues rather than investigate failings, according to Ockenden. Additionally, a baby who died early in gestation was inadvertently disposed of as clinical waste by laboratory staff after a post-mortem examination. The inquiry concluded that the deaths of newborns would most likely have been prevented with proper hospital care.

Several clinicians declined to respond to questions from the Ockenden inquiry. The Nottingham Maternity Families group, which represents 600 harmed and bereaved families, called for the removal of senior managers who did not provide evidence. The group also urged the government to initiate a statutory public inquiry into maternity failings across England.

Kath Abrahams, chief executive of the baby loss charity Tommy's, commented on the findings. "This is a truly harrowing report," Abrahams said. "It is utterly inexcusable that pregnant women seeking help at Nottingham University Hospitals NHS Trust were in some cases treated so poorly – sometimes with devastating consequences – and that healthcare professionals and families who did as much as they could to flag the risks were ignored."

Why It Matters

The Ockenden inquiry's findings reveal systemic failures in maternity care at a major hospital trust, affecting hundreds of families over more than a decade. The report's identification of a bullying culture, understaffing, and management's failure to address repeated warnings suggests deeper issues within the healthcare system's oversight and accountability mechanisms. These findings align with broader concerns about maternal care standards, as research published by Oxford University indicated that the UK maternal mortality rate for 2022-2024 was 12.8 deaths per 100,000 maternities. This figure represents a 20 percent increase from the 2009-2011 rate, indicating a missed ambition to halve maternal mortality.