More than 500 mothers and babies ‘died or suffered avoidable harm’ at ‘toxic’ NHS trust

More than 500 mothers and babies suffered potentially avoidable harm or died due to ‘deeply embedded systemic failures’ at a ‘toxic’ hospital trust, a damning review has found.

Bosses at Nottingham University Hospitals NHS Trust (NUH) knew there were serious issues in its maternity department going back years but failed to take action to prevent more deaths, a report by senior midwife Donna Ockenden concluded.

Among the key findings were women and families consistently not being listened to, leading to missed opportunities to prevent harm; and failures to recognize and escalate deterioration in babies’ and mothers’ health.

Overall, 520 mothers and babies suffered potentially avoidable harm or death, including 94 babies who were stillborn.

Experts on Ms Ockenden’s review team found deep-rooted problems, adding that failures in care ‘may have or substantially impacted on the outcome in six deaths’ of women.

There were 62 neonatal deaths of babies overall.

Assessors found babies died from a range of conditions, including oxygen starvation, mismanaged labor, hospital-acquired infections and poor postnatal care delivered by midwives and doctors.

More than 2,500 families and over 800 members of staff have contributed to the largest maternity inquiry in the history of the NHS, with NUH having already paid out millions of pounds in compensation and fines after being prosecuted for poor care.

Among the babies who died were Harriet Hawkins, who died ‘avoidably’ in 2016 following ‘significant failures in maternity care’; Wynter Andrews, who died in 2019 ‘after significant failures in care’; and Ladybird, whose parents were wrongly told to terminate a healthy pregnancy, the report said.

Overall, experts on the review concluded there were ‘potentially avoidable’ outcomes relating to 444 maternity cases examined up to May 2025, alongside 76 neonatal (newborn) cases.

All these cases were graded as 2 or 3 for harm, with grade 2 representing ‘significant concerns’ and grade 3 ‘major concerns’ over care.

Grade 2 represents sub-optimal care where different management might have made a difference to the outcome, and grade 3 is where different management would reasonably be expected to have made a difference.

Overall, 31 reviews into baby neonatal deaths at the trust were found to include potentially avoidable harm at grades 2 and 3. At least eight of these babies should have survived.

Another 30 cases of potentially avoidable harm related to ‘massive obstetric haemorrhage’, and 12 reviews into babies were found to have significant or major concerns relating to brain damage due to a lack of oxygen.

Looking at the catalog of errors spanning many years, the report found failures in the monitoring of babies, poor CTG interpretation, a failure to recognize babies were in distress during labor and a failure to escalate some cases to senior doctors.

‘In a number of cases these failures contributed to severe neonatal injury, stillbirth and neonatal death,’ the report said.

In several cases, following a birth, ‘babies who demonstrated signs of poor feeding, hypoglycaemia, infection or clinical deterioration were not appropriately assessed or escalated, leading to avoidable harm and, in some instances, death’.

Assessors also found that some families who raised concerns with the trust were told lessons would be learned, and yet ‘similar incidents recurred repeatedly over many years’.

There was also ‘evidence that harm was sometimes downgraded’ by the trust, while some families were told babies had died of natural causes when that was not true.

‘Across multiple cases and over many years, opportunities to recognize deterioration, escalate concerns and intervene appropriately were missed,’ the report said.
Experts on Ms Ockenden’s team also found:

• ‘Multiple examples where failures in neonatal care may have contributed to long-term brain injury and adverse neurodevelopmental outcomes’ in babies.
• Leadership instability was a ‘major contributing factor’ affecting the quality and safety of maternity services. Between 2017 and 2021 there was ‘sustained turnover in senior maternity leadership positions’ and senior operational roles.
• A ‘bullying and toxic culture’ at the trust over years. The review team heard how some staff members were ‘specifically and consistently mentioned as forming intimidating cliques that were/are well known, but not confronted or challenged’.
• Staff also ‘reported experiences shaped by longstanding cultural challenges, including hierarchy, bullying (particularly by some labor ward co-ordinators), nepotism and aggressive behavior’.
• Staff reported ‘a culture of organisational denial’ over years, where poor outcomes ‘were regularly dismissed as “known complications”’.
• There were multiple examples of ‘poor telephone risk assessment’ of women ringing in with concerns during pregnancy and labor, alongside missing documentation and a ‘culture of discouraging women to attend in-person’.
• Staff who worked at NUH before 2017 told the review team ‘there was a culture of not admitting women who were seeking admission in labor’. One staff member said: ‘There was nowhere for those women to safely go to, because they were perceived as bed-blocking on labor suite.’ They said there was a lack of staff and ‘honestly, when I worked there, it would be when they complained enough, when they complained loud enough…’
• Some women in labor suffered delays in being examined, and there were cases where staff were reluctant to escalate concerns and transfer to the labor ward ‘due to professional cultures’.
• The ‘toxic bullying culture among labor ward co-ordinators’ lasted years and resulted in women receiving inadequate care. Reviewers also found inappropriate use of the drug oxytocin to induce labor.
• There were delays in recognition and escalation of postpartum haemorrhage, as well as major obstetric haemorrhage, causing women harm.
• With antenatal care, women repeatedly described feeling unheard, inadequately informed and unsupported when expressing anxiety, particularly in relation to reduced foetal movements or emerging medical complications.
• There was inadequate communication support for women whose first language was not English.
• In postnatal care, some mothers with very high blood pressure or who were deteriorating were not adequately assessed, and there were ‘failures in the recognition and management of the unwell or poorly feeding baby’. Some patients received phone calls when they should have been seen in person. ‘In several cases the consequences of these failures were severe and irreversible.’
• Managers at the trust were often thought of as ‘invisible, unapproachable and unresponsive’ – they ignored concerns, bullied people, and were rude and aggressive.
• From at least 2012 there was a ‘running theme of poor governance within maternity’, including serious incidents not being investigated and a failure to learn and change after incidents.
• Staff shortages and ‘operational pressures’ affected all areas of maternity. Staff described routinely working ‘beyond safe capacity’.
• Some patients described inadequate pain relief, with one saying ‘It felt brutal… traumatic… they were screaming at me… “you need to pull yourself together”…’
• Another patient said staff were dismissive and said ‘Is this your first baby…? Take some paracetamol and have a hot bath.’

The review also examined 17 babies and one adult who died and what happened to them after death.

It found ‘recurring examples of failure to protect the dignity of the deceased, including an early gestation baby disposed as clinical waste; dehumanising language by clinicians; and poor mortuary care, including failure to comply with legal requirements…’

On Monday, Nottinghamshire Police said two men had been arrested ‘in connection with operating practices in the mortuary service’ provided by the trust.

In her introduction to the report, Ms Ockenden said: ‘We owe it to every mother, every baby and every family whose terrible experiences are recorded here that they are never repeated.’

She added that ‘the culture of compounding of harm needs to stop’.

Detailing the case of Jack and Sarah Hawkins, she said baby Harriet’s ‘avoidable death was compounded by a systemic cover-up and investigations designed to mislead, which took a profound toll on the couple’s wellbeing’.

She added that the list of organisations that failed the Hawkins family include the trust, the Nursing and Midwifery Council, the Human Tissue Authority and the Care Quality Commission (CQC) regulator.

Ms Ockenden added that many of the systems of oversight established for maternity care ‘are no longer fit for purpose’.

Actions set down in the review ‘when implemented will drive improvement both within perinatal services at Nottingham University Hospitals NHS Trust and across England’, she said.

‘The evidence heard by the review team makes clear that we are not yet consistently providing safe, equitable and compassionate care to all women, babies and families. That must change.’

Clea Harmer, chief executive of Stillbirth and Neonatal Death Charity (Sands), said: ‘Reading Donna Ockenden’s report is absolutely heartbreaking. First and foremost, we must keep those families impacted by what happened in Nottingham in our minds today.

‘There is also a lot of anger and frustration, when we hear that so many parents and families and their babies experienced such poor care, and were treated with a lack of kindness and compassion for so long.

‘These personal testimonies reveal trauma and pain that was compounded by families not being listened to or believed, and opportunities for lessons to be learned, ignored. This was the opposite of what high-quality maternity care that treats parents as individuals looks like.

‘Listening with belief and respect should be at the heart of the care given to families, regardless of who they are or what their background or ethnicity is. The Nottingham families who have fought for accountability and justice cannot be let down again.’

Ms Ockenden suggested a new national framework for clinical governance introduced to hospitals in England in 2022 may also have flaws.

She said ‘like many other trusts NUH has struggled to implement PSIRF (Patient Safety Incident Reporting Framework).

‘In maternity, the policy for including incidents is vague, resulting in under-reporting.’

Health Secretary James Murray pledged to ‘deliver lasting change’, adding: ‘We will reflect on these findings and lessons from Nottingham will form part of our national plan to deliver real improvements in maternal and neonatal care for all families.’

The Department of Health and Social Care (DHSC) said on Wednesday that Martha’s Rule will be extended to all maternity settings in England, so parents can request a rapid review if a baby or mother’s condition is deteriorating and they are concerned staff are not responding to this.

The scheme has been rolled out for inpatients in every acute hospital in England and has been piloted in 15 maternity and neonatal settings, with rollout to more expected this year.

Nick Carver, NUH trust chairman and Anthony May, chief executive, who both joined in 2022, apologized in an open letter and said while improvements have been made, there is more to do.

They added: ‘We apologize unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services.’

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