An independent review into maternity services at Nottingham’s hospitals has found that hundreds of mothers and babies suffered potentially avoidable harm over a number of years, with investigators identifying serious concerns about patient safety, leadership and workplace culture.
The review, led by senior midwife Donna Ockenden, examined 2,460 cases involving more than 2,000 families who received care from Nottingham University Hospitals NHS Trust (NUH), which runs Queen’s Medical Centre and Nottingham City Hospital.
Published on Wednesday, the report is the largest maternity review ever carried out in the history of the NHS.
Review teams found potentially avoidable harm in 444 maternity cases and a further 76 neonatal cases. Investigators concluded that different care may have altered the outcome for 260 babies who either died or suffered serious injury.
Of those cases, 155 babies died and 105 suffered serious harm linked to substandard care, including some who were left with permanent brain injuries.
The review concluded that many of the failings were not isolated incidents but formed part of wider systemic problems that had existed within the trust for years.
Speaking as the report was published, Donna Ockenden said many of the issues identified had been known about since at least 2010 but had not been adequately addressed.
The review found that adverse outcomes were often linked to a combination of factors, including failures to monitor babies appropriately, poor interpretation of heart monitoring traces, delays in recognising when babies were in distress during labour and failures to escalate concerns to senior clinicians.
Women and families repeatedly reported feeling that their concerns were not listened to.
The report found many mothers felt unheard, inadequately informed and unsupported when raising concerns during pregnancy, particularly when reporting reduced foetal movements or emerging complications.
Investigators said concerns were often dismissed or minimised, reducing opportunities to identify deterioration and intervene before harm occurred.
The review also highlighted concerns around communication with families whose first language was not English and included evidence from staff describing instances of racism and discriminatory attitudes towards some patients.
One of the most damning sections of the report focuses on workplace culture within the maternity service.
Investigators described a “bullying and toxic culture” which persisted over a number of years, with some staff reporting that speaking up about concerns could be difficult.
The report refers to intimidating cliques, a culture of organisational denial and a belief among some staff that poor outcomes were simply unavoidable complications rather than opportunities to learn lessons and improve care.
Leadership instability was also identified as a significant contributing factor. Between 2017 and 2021, there was sustained turnover in a number of senior maternity leadership and operational roles.
The review heard from staff who believed poor behaviours had become normalised within parts of the service, while others described an environment where governance and decision-making were too often focused on protecting reputations rather than improving patient safety.
Investigators also identified failings in bereavement and post-death care which caused additional distress to families already dealing with the loss of a baby.
One incident involved the wrong baby being released to a funeral director. In another case, a baby’s remains were mistakenly disposed of following a post-mortem examination.
The report concludes that these incidents represented serious failures in dignity, communication and care for grieving families.
A number of actions have now been recommended for Nottingham University Hospitals NHS Trust.
These include improvements to risk management, stronger escalation procedures when concerns are raised, better communication between clinical teams, enhanced training for maternity and neonatal staff and greater consistency in emergency care.
The review also calls for improvements in bereavement services, better support for women whose first language is not English and measures to address bullying and encourage staff to raise concerns without fear of repercussions.
Responding to the findings, Nottingham University Hospitals NHS Trust issued a further apology to affected families.
The trust said it fully accepts the findings of the review and acknowledged that many families received care that fell below the standards they should have expected.
Hospital leaders said improvements have already been made in recent years, including increased maternity staffing, investment in specialist roles, improvements to fetal monitoring, enhanced staff training and changes to patient safety procedures.
The trust has committed to implementing the review’s recommendations and continuing work to improve services.
While the review focuses on Nottingham, Donna Ockenden said the findings carry important lessons for maternity services across England.
Many families from Ilkeston, Erewash and the wider Derbyshire area have used maternity services at Queen’s Medical Centre and Nottingham City Hospital over the years, making the findings particularly significant locally.
For the thousands of families who contributed to the review, Wednesday’s publication marks the end of a long campaign for answers. Attention will now turn to whether the recommendations lead to the lasting changes that many families have called for.