Ockenden Review delivers final report into maternity care in Nottingham

The Ockenden Review into maternity care in Nottingham has revealed that there were potentially avoidable outcomes relating to 444 maternity cases and 76 neonatal cases.

The Review, led by former midwife Donna Ockenden, found leaders at Nottingham University Hospitals NHS Trust knew there were issues in its maternity department dating back to at least 2010 but they failed to take action to prevent more harm.

Problems included insufficient staffing, the inability of staff to carry out basic and often mandatory training, a persistent failure to listen to and believe mothers and fathers, and a failure to investigate and learn from mistakes.

Around 2,500 families and more than 800 members of staff contributed to what is believed to be the largest NHS maternity review.

Overall, experts working as part of the review concluded there were "potentially avoidable" outcomes relating to 444 maternity cases examined up to May 2025, alongside 76 newborn cases.

Irwin Mitchell’s specialist medical negligence team represents families affected by poor maternity care nationally, including in Nottingham. Lawyers say many of the experiences described in the Ockenden Inquiry report reflect issues they regularly see in cases involving maternity failures.

Tania Harrison, a specialist medical negligence lawyer at Irwin Mitchell in Nottingham supporting families affected by maternity care failings, said: 

“The findings of the Ockenden Review are deeply distressing and will be incredibly difficult for families who have already endured unimaginable harm and a prolonged search for answers.

 

“Behind every case is a family whose life has been changed forever. Many describe not only devastating clinical outcomes, but also a failure to listen, a lack of transparency and a sense that their concerns were dismissed when they should have been acted upon.

 

“Every mother and baby is entitled to safe, compassionate and respectful care. No one should feel ignored, belittled or unsafe at such a vulnerable time.

 

“While the scale of this review is shocking, the themes are sadly familiar. Time and again, maternity investigations have identified families not being listened to, warnings not being acted upon, poor communication, and missed opportunities to learn from serious incidents.

 

“It is now vital that the voices of families are central to what happens next. This Review cannot be allowed to sit on the shelf collecting dust, recommendations made must be implemented in a meaningful, measurable and sustained way so that patient safety can be improved.

 

“Families deserve answers, accountability and assurance that lessons will be learned so that others do not have to experience the same avoidable harm.”

The Ockenden Review was established following significant concerns about the quality and safety of maternity services at Nottingham University Hospitals NHS Trust. It has considered cases over a period of more than a decade and is expected to make recommendations aimed at improving safety within maternity and perinatal services.

Irwin Mitchell says that, where maternity care falls below acceptable standards, families must be given clear explanations about what happened, access to appropriate support and, where failings are identified, a commitment to action that prevents the same issues being repeated.

Irwin Mitchell’s own Maternity Care Report which recently surveyed 1000 expectant and new parents found that one in five parents don’t feel confident in maternity care. Almost half of respondents (46%) said that staffing shortages was their top concern with 41 per cent saying that postnatal care fell short of expectations.