An independent inquiry into maternity services at Nottingham University Hospitals NHS Trust (NUH) has uncovered more than 500 cases of potentially avoidable harm spanning over a decade, highlighting systemic failures that affected hundreds of mothers and babies. The comprehensive 400-page report, published in June 2026, reveals significant shortcomings in care that resulted in numerous stillbirths, neonatal deaths, and serious injuries.
The investigation, commissioned in 2020 following media revelations, was led by senior midwife Donna Ockenden. It found that between 2010 and 2023, 94 stillbirths and 62 neonatal deaths occurred under conditions suggesting preventable factors. Additionally, 120 babies sustained brain injuries, and nine were left with cerebral palsy. The report also identified failures contributing to the potentially avoidable deaths of six mothers. Furthermore, 31 women experienced life-threatening obstetric bleeding, and 20 women suffered severe tears during labor.
The inquiry highlighted a pattern of systemic failings entrenched within NUH’s maternity services, describing them as “hauntingly consistent” despite repeated awareness by hospital leaders. Vulnerable women were frequently dismissed or disbelieved, with some accused of “imagining pain” and subsequently denied timely care. The report criticized the trust’s mortuary services for instances of undignified treatment of deceased infants, including a case where a baby’s body was found in a clinical waste bin.
The review also detailed a culture of bullying by a “small minority of powerful leaders” who influenced staff and service delivery negatively across two maternity units. A pronounced institutional emphasis on minimizing medical intervention, driven by a “quest” to increase vaginal births, was linked to adverse outcomes. This approach, aimed at reducing interventions, sometimes resulted in delayed or insufficient responses to complications.
Ms. Ockenden acknowledged the trauma endured by thousands of families who contributed to the inquiry and called for their experiences to drive meaningful national reform in maternity care. The report’s publication marks a critical moment in addressing longstanding problems within the NHS, with a focus on improving patient safety, staff culture, and clinical governance to prevent future harm.