Ockenden Report into Nottingham University Hospitals Trust Maternity Services

The publication of the Ockenden Report into maternity and neonatal services at Nottingham University Hospitals NHS Trust marks a pivotal moment for maternity care across England.

This independent review, one of the largest maternity inquiries undertaken within the NHS, has identified longstanding issues in leadership, governance, clinical practice and organisational culture. Over 2,500 families and 800 staff provided evidence . This is significant, but it marks the first recognition for many families that their care, even over a decade ago, was unsafe. That the harm and enduring trauma they suffer should never have happened. With their many questions comes a significant request: accountability and change via a public inquiry.

Over a period of more than a decade, too many women, babies and families experienced care that fell below the standard they should reasonably expect. At its heart, the report reflects the impact of a system that did not consistently listen to women, respond effectively to concerns, or embed learning from previous incidents. Families described experiences in which concerns were not always recognised or acted upon promptly, and in some cases, action was taken only after situations had escalated.

The findings also point to wider systemic challenges, including evidence of discrimination and inequalities in care, with some women, particularly those from ethnic minority backgrounds, facing additional barriers in being heard and receiving appropriate treatment.

Alongside this, a number of staff reported working within environments affected by toxic workplace cultures, including bullying and a lack of psychological safety, which impacted their ability to raise concerns and deliver safe care.

Importantly, the report also recognises the experiences of fathers and partners. Many described feeling excluded from decision-making, unable to effectively advocate for the women they were supporting, and left without clear communication or support during critical moments.

More so, being left behind when their children or partners were harmed or died. Their perspectives reinforce the need for maternity care to fully recognise and involve the wider family.

The findings highlight recurring themes: missed opportunities, delays in escalation, weaknesses in communication and variations in the quality of care. These were not isolated incidents but patterns that developed over time and require a clear and coordinated response.

Rebuilding trust in maternity services will depend on consistent, demonstrable change.

A call for accountability and national action

We recognise the courage of the families who contributed to this review. Their willingness to share their experiences has been central to bringing these issues to light. Simply, without the families, this review would not have happened.

The themes identified in this report are not unique to one organisation, but we cannot lose sight of the fact that they reflect the current and past working of the Trust, and they must be held to account. Additionally, similar issues have been highlighted in other maternity reviews nationally. Change has been slow, if not at a standstill.  This underlines the need for a broader, system-wide response.

We therefore believe that:

• Accountability must be clear and transparent, both locally and across the wider system.
• There must be real, tangible and measurable change in the way maternity services are delivered and governed.
• Lessons must be consistently implemented and sustained, with clear oversight and responsibility.
• Consideration should be given to a full, independent national public inquiry into maternity services, to ensure that learning is applied consistently and comprehensively.

Natalie Cosgrove, a Medical Negligence Partner at Ashtons Legal, says: “This report reflects the experiences of many families who have faced loss, trauma and uncertainty over a prolonged period. It is clear that concerns were repeatedly raised without consistent action, and this must now be addressed.

It is also important to recognise the wider issues highlighted, including inequalities in care, the toxic work culture that fed into the provision of unsafe care, and the experiences of fathers and partners who often felt and feel excluded at critical moments.

We need to see genuine accountability and sustained, meaningful change in how maternity services operate.

There is also a strong case for a national public inquiry, so that these issues can be examined in full and improvements can be implemented consistently across the country.”

Looking ahead

The Ockenden Report provides a clear framework for improvement. Its impact will depend on how effectively its findings and recommendations are implemented across the NHS and within the wider maternity system.

Ensuring safe, consistent and compassionate care must remain a shared priority. The opportunity now is to translate these findings into meaningful action, so that families can have confidence in the care they receive at a critical time in their lives.