An independent inquiry into maternity care at Nottingham hospitals has revealed systemic failures contributing to the deaths and harm of hundreds of babies and mothers over more than a decade. The report attributes the incidents to deeply embedded problems including leadership shortcomings, a culture that tolerated bullying, suppression of concerns, and the dismissal of women’s voices.

Authored by senior midwife Donna Ockenden, the inquiry highlights how these failures were compounded by an environment where incidents were often downgraded and warnings ignored. Ockenden emphasized that safe maternity care should be straightforward in ambition, grounded in competence, honesty, timeliness, safety, dignity, and kindness—standards she stated “are not high bars.” She urged that the National Health Service (NHS) must be assessed not only on its achievements but also on its ability to prevent harm, underscoring the importance of learning from these tragic experiences to ensure they are never repeated.

The inquiry’s findings have prompted calls from affected families for further action. Jack Hawkins, whose daughter Harriet was stillborn in 2016, spoke out following the report’s release, describing the need for full implementation of its recommendations to avoid a “betrayal” of those impacted. Hawkins, who initially did not intend to become an activist, said the failure of responsible authorities to listen left families no choice but to campaign for justice and reform. He and his wife, Sarah, along with other families, attended the hearing in Nottingham as the inquiry was formally presented.

The report has also generated demands for a public inquiry to provide greater transparency and accountability. Advocates argue that a more extensive examination is necessary to bring about lasting change and overhaul leadership structures within maternity services. Ockenden described the inquiry as a catalyst for reform, emphasizing that addressing the entrenched issues exposed is vital for protecting mothers, babies, and families in the future.

While the report highlights significant deficiencies in leadership and care at Nottingham’s maternity units, it also serves as a broader warning about risks within NHS maternity services, underscoring the critical need for culture change and strengthened oversight across the healthcare system.