The publication of the Nottingham Maternity Review in June 2026 has exposed a catalogue of failings spanning several years. Leading to a conclusion of embedded systemic failings, the four year investigation was led by independent midwife Donna Ockenden.
Examining more than 2,500 cases involving mothers and babies who experienced serious harm while under the care of Nottingham University Hospitals NHS Trust between 2012 and 2025, the review found hundreds of potentially avoidable incidents.
Serious harm was found to have been caused to mothers and babies including significant brain damage, stillbirths, neonatal deaths and maternal deaths. It is the largest maternity review ever undertaken in the NHS.
For many couples, particularly those planning to start or grow their family, reading about the review and other high profile maternity investigations across the country, will be understandably worrying. Being informed of the highlighted failings will help better equip parents about the level of care to expect from their hospital.
What did the review find?
Donna Ockenden’s conclusions were stark. Her team found that maternity care failures at Nottingham were not isolated incidents but part of a pattern of systemic problems that have been allowed to persist for many years. The birth injury experts at Diane Rostron are supporting families failed in Nottingham dating back to more than 15 years ago.
The report found that hundreds of mothers and babies experienced potentially avoidable harm. Among the cases reviewed, 444 women and 76 babies suffered outcomes that the review considered potentially avoidable had appropriate care been provided.
Investigators identified recurring themes that are sadly echoed in many hospitals in England and Wales, including:
- Failure to recognise and respond to signs that mothers or babies were becoming seriously unwell
- Delays in escalating concerns and seeking senior clinical support
- Poor communication between healthcare professionals
- Inadequate investigations following serious incidents
- Failure to learn lessons from previous mistakes
- Chronic staffing shortages and insufficient training
- A workplace culture in which concerns were ignored, minimised or dismissed
One of the most concerning findings was that serious maternity incidents were sometimes downgraded or classified as unavoidable when the review team believed better care might have changed the outcome. This prevented proper scrutiny and learning.
A culture that failed families
One of the strongest messages from the report is that the problems were not simply clinical. They were cultural.
The review describes a bullying and toxic environment where staff often felt unable to speak up. Families repeatedly reported not being listened to when they raised concerns about their own health or their baby’s wellbeing. Some women described feeling dismissed when they instinctively knew something was wrong including when they reported experiencing less frequent baby movements.
The review also highlighted evidence of racism, stereotyping and discrimination affecting the experiences of some women and families. These findings are particularly alarming given the well reported inequalities in maternity outcomes among women from Black, Asian and minority ethnic communities. These women and their babies are at a higher risk of suffering serious harm when compared to the statistics for Caucasian families.
Throughout the report, a common theme emerged: families often knew something was wrong, but their voices were not heard.
What does this mean for the families harmed?
For the thousands of families involved, the publication of the report is both devastating and validating.
Many parents spent years campaigning for answers after the deaths of their babies, or suffering life-changing injuries, traumatic births or the loss of the mothers. Some felt they had been blamed, ignored or misled when they first asked for explanations. The review confirms that many of their concerns were justified.
No report can undo the grief experienced by families who lost loved ones or whose children now live with lifelong disabilities. However, the findings provide official recognition of what many have been saying for years: that serious failures occurred and that those failures should never have happened.
Many families are now calling for a full statutory public inquiry to establish accountability and to ensure lessons are learned nationally.
Should pregnant women be worried?
It is understandable that news coverage of the review may cause anxiety. It is important to remember however, that the Nottingham review examined historical cases spanning more than a decade. The majority of births in England and Wales continue to result in safe outcomes, and many maternity teams provide excellent care every day.
At the same time, the report serves as a reminder that women should always feel empowered to ask questions, raise concerns and seek help if something does not feel right.
One of the key lessons from Nottingham is that women must be listened to. A mother’s concerns about reduced baby movements, pain, bleeding, changes in her baby’s behaviour or her own health should never be dismissed without proper assessment.
What changes are expected across England and Wales?
Although the review focused on one NHS trust, Donna Ockenden has been clear that Nottingham is not an isolated case. Many of the issues identified have also appeared in previous maternity investigations elsewhere in England including Shropshire and East Kent.
As a result, the report is expected to influence maternity services nationwide. The key areas that are likely to see change include:
- Improved listening to women and families
- Services are being encouraged to place women’s voices at the centre of maternity care. Families should be treated as partners in decision-making, not passive recipients of care
- Stronger safety escalation processes
- The Government has announced plans to expand “Martha’s Rule” into maternity settings. This allows patients and families to request an urgent second opinion if they believe concerns are not being taken seriously
- Improved staffing and training.The review repeatedly identified workforce shortages and gaps in skills. National attention is now likely to focus on recruiting, retaining and supporting maternity staff while ensuring ongoing training and professional development
- Better investigations and accountability. The report calls for greater transparency when things go wrong. Serious incidents must be investigated honestly, and organisations must learn from mistakes rather than defend reputations
- Tackling inequality and discrimination. The findings around racism and stereotyping reinforce the need for maternity services to address inequalities and provide culturally safe care for all women
The bigger picture
The Nottingham Maternity Review is ultimately about more than one hospital trust. It is about trust itself.
Women deserve maternity services that are safe, compassionate, responsive and respectful. Families deserve to be heard. Staff deserve workplaces where they can raise concerns without fear.
The review paints a painful picture of what can happen when these principles are lost. Yet it also offers an opportunity for meaningful change. By listening to families, learning from mistakes and putting women at the centre of care, maternity services across England and Wales can become safer for future generations.
For the families whose experiences shaped this review, that change is the legacy they hope will emerge from years of heartbreak—and the reason their voices must continue to be heard.