Hundreds of mothers and babies suffered avoidable harm or died due to “deeply embedded systemic failures” at Nottingham University Hospitals NHS Trust’s maternity department, an extensive inquiry by Donna Ockenden reveals. The report highlights how hospital leadership ignored serious issues, perpetuating a “toxic” culture that put patients at risk.
Historic Mistakes Exposed
The Ockenden inquiry, the largest maternity review in NHS history, examined 444 maternity cases and 76 newborn cases up to May 2025, finding multiple preventable tragedies caused by oxygen deprivation, mismanaged labour, infections, and substandard postnatal care.
Leadership And Culture Failures
Experts point to leadership instability and a “bullying and toxic culture” as central factors in the crisis. Staff reported that before 2017, women in labour were often refused admission and that managers were “invisible, unapproachable and unresponsive,” fostering a hostile work environment.
Patient Experience And Safety Concerns
Mothers described feeling ignored, inadequately informed, and unsupported, especially when expressing anxiety or requiring pain relief. Communication barriers compounded risks for non-English speakers. Serious conditions like postpartum haemorrhage and high blood pressure were not properly recognised or treated.
Calls For Full Public Inquiry
Bereaved mother Sarah Hawkins criticised regulators and demanded a full statutory public inquiry, emphasising the need for accountability. Hawkins condemned staff who refused to give evidence, questioning if those clinicians prioritise patient safety at all.
Ongoing Impact And Compensation
Prior to the report’s release, Nottingham University Hospitals NHS Trust had already paid millions in fines and compensation following legal action over poor maternity care, underscoring the scale of the failings uncovered.
