Hundreds of mothers and babies died or suffered potentially avoidable harm because of “deeply embedded systemic failures” at a Nottingham hospital trust where leaders knew about serious problems in the maternity department but failed to act, the largest maternity inquiry in NHS history has concluded.
Donna Ockenden’s major inquiry into Nottingham University Hospitals NHS Trust found that potentially avoidable outcomes were linked to 444 maternity cases examined up to May 2025, alongside 76 newborn cases. Babies died from oxygen starvation, mismanaged labour, hospital-acquired infections and poor postnatal care. The trust had already paid out millions in compensation and faced prosecution for poor care before the report was published.
The inquiry’s experts uncovered years of leadership instability described as “a major contributing factor,” alongside a “bullying and toxic culture” that persisted across the trust and directly resulted in women receiving inadequate care. Managers were routinely described by staff as “invisible, unapproachable and unresponsive.” Staff who worked at the trust before 2017 told the review team there was an entrenched culture of “not admitting women who were seeking admission in labour.”
Multiple examples were found where failures in neonatal care “may have contributed to long-term brain injury” and other neurodevelopmental outcomes in babies. The report also identified delays in recognising and escalating postpartum haemorrhage, causing women serious harm, and found that some mothers with very high blood pressure or who were deteriorating were not adequately assessed after birth.
Women’s accounts of their treatment were harrowing. One patient said of her experience: “It felt brutal… traumatic… they were screaming at me… ‘you need to pull yourself together.'” Another was told by staff: “Is this your first baby…? Take some paracetamol and have a hot bath.” The inquiry found that women repeatedly described feeling “unheard, inadequately informed and unsupported when expressing anxiety,” and that women whose first language was not English received inadequate communication support.
