The publication of Donna Ockenden’s Review into maternity and neonatal services at Nottingham University Hospitals NHS Trust has become the largest maternity investigation in NHS history. Through detailed reviews of individual cases, interviews with families and staff, and analysis of governance records and previous investigations, the Review identified long-standing and systemic failings across almost every stage of maternity care.

The findings are both shocking and deeply upsetting. More than one in five maternity cases reviewed were found to involve potentially avoidable harm, affecting hundreds of families through stillbirth, neonatal death, birth injury, and trauma. The Review concluded that women, babies and families were repeatedly failed by a maternity service that: “too often did not listen, did not learn, and did not respond adequately when concerns were raised.”

The Review also highlights the lasting impact these experiences can have on families, with many reporting ongoing psychological injuries including post-traumatic stress disorder (PTSD), anxiety and depression, often compounded by poor communication and a lack of openness following adverse events.

The Key Findings

The investigation identified a number of recurring themes that stretched back more than a decade, revealing concerns that were repeatedly raised but not adequately addressed:

• Failure to Listen to Women and Families

One of the most consistent themes was that families felt their concerns were not taken seriously. Women described reporting reduced fetal movements, changes in their symptoms, concerns about labour progression, or worries about their baby’s wellbeing, only to feel dismissed or reassured without appropriate assessment. Families frequently described not being listened to until a situation became critical.

• Delays in Recognising and Responding to Risk

The Review identified repeated failures in clinical assessment, monitoring and escalation. Examples included shortcomings in antenatal risk assessment, poor management of reduced fetal movements, failures in fetal heart monitoring during labour, delays in recognising maternal deterioration, and missed opportunities to intervene when complications developed. It was concluded that, in many cases, earlier recognition and action may have altered or improved outcomes.

• Workforce Pressures and Unsafe Cultures

Staffing shortages emerged as a significant concern throughout the Review. Staff described working in stretched services with insufficient resources, limited opportunities for training, and high levels of stress and burnout. Only 11% of staff reported that staffing levels were sufficient to meet demand. More than 40% reported either witnessing or experiencing bullying within the maternity service. The Review found that workforce pressures and organisational culture had contributed to an environment where concerns were not always raised, heard or acted upon effectively.

• Governance Failures and Missed Learning Opportunities

Perhaps most concerningly, many of the problems uncovered were not new. Multiple reviews, inspections and internal investigations had identified concerns over many years, yet lessons were not consistently learned or embedded into practice. Failures in incident reporting, inadequate investigations, poor board oversight and a culture which often favoured reassurance over challenge meant opportunities for meaningful improvement were missed.

The Wider Significance Of The Ockenden Report

While the Review focuses on Nottingham University Hospitals NHS Trust, the issues identified are not unique to one organisation. Many of the themes emerging from the investigation mirror findings from previous maternity reviews across England and will sadly sound familiar to families and clinical negligence practitioners alike.

At the heart of the Ockenden Review are the voices of thousands of families who shared their experiences in the hope that future patients would not endure similar harm. Their contribution has shone a light on issues that cannot be ignored and has reinforced the need for sustained national efforts to improve maternity care.

When Might There Be A Medical Negligence Claim?

Not every poor outcome during pregnancy or childbirth is the result of negligence. Complications can and do occur, even where appropriate care is provided. However, a legal claim may arise where there is evidence that a healthcare provider failed to provide reasonable care and that failure caused or contributed to an injury or loss.

At Wollens, we have represented families affected by many of the same issues identified in the Ockenden Report, including: 

• Failure to recognise or act upon reduced fetal movements.
• Delayed diagnosis of fetal distress.
• Delays in performing an emergency Caesarean section.
• Failures in monitoring during labour.
• Delayed recognition of maternal deterioration.
• Inadequate communication or escalation of concerns.
• Failures in postnatal care resulting in avoidable injury.

We understand that no legal outcome can undo the loss of a child or reverse a life-changing injury. For many families, obtaining answers and understanding whether different care could have altered the outcome is just as important as any financial compensation.

Our team works closely with independent obstetric, midwifery, neonatal and other medical experts to investigate what happened, assess whether the care provided met an acceptable standard, and determine whether any failings contributed to the harm suffered.

If you have concerns about maternity care, birth injury, stillbirth, neonatal injury or maternal harm, our specialist Clinical Negligence solicitors can help you understand your options and whether further investigation may be appropriate.

For a confidential, no-obligation discussion with a member of our team, please contact Wollens’ Clinical Negligence department. Our approach is to provide clear, compassionate and practical advice throughout what is often an extremely difficult and personal process.

You can also complete an online enquiry form. One of the Wollens team will contact you as soon as they are available.