520 Mothers, Babies Harmed in NHS Maternity Scandal

A three-year review has found that 520 mothers and babies suffered harm or died at a single NHS trust in maternity care campaigners are calling the worst scandal of its kind in NHS history.

Health Secretary James Murray called the findings "horrific" and "chilling."

What the Review Actually Found

The independent review, led by maternity safety expert Donna Ockenden, examined care at Nottingham University Hospitals NHS Trust between 2012 and 2025.

It concluded that 444 women and 76 newborn babies experienced outcomes the report describes as "potentially avoidable," according to the Guardian's reporting on the findings.

Ockenden's 401-page report described a pattern of routine understaffing, lessons from safety incidents that went unlearned, and bullying by what she called "intimidating cliques" of staff across both of the trust's hospitals, Queen's Medical Centre and Nottingham City Hospital.

Nearly 2,500 families took part in the review by the time it closed, alongside more than 800 current and former NUH staff who gave evidence.

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The Deaths Behind the Numbers

Ockenden's team separately investigated the deaths of 27 mothers between 2006 and 2024, identifying care failures that may have substantially affected the outcome in six of those cases.

A common thread across the maternal deaths was staff not listening to women or acting promptly when concerns were raised, alongside delays in scans that might have caught problems earlier.

The review also examined newborn deaths linked to oxygen deprivation during birth, hospital-acquired infection, and labour that was not properly managed. Detailed examination of 31 newborn deaths concluded that different care would probably have prevented the harm in each case.

Recurring clinical failures identified across these cases included staff misreading fetal heart-rate monitoring, not recognising when babies were in distress, and midwives failing to escalate worrying signs to doctors quickly enough.

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Why a Public Inquiry Is Now on the Table

The Nottingham Maternity Families group, representing roughly 600 affected families, has formally asked Prime Minister Keir Starmer to launch a statutory public inquiry into maternity and neonatal care across the entire NHS.

A statutory inquiry would carry a power Ockenden's review did not have: the ability to compel witnesses to testify.

That distinction matters because of what the review's own data shows. Almost half of the 66 current and former NUH executives asked to take part in the review declined to engage, despite repeated requests, and only four of 14 contacted leaders from local NHS oversight bodies agreed to speak with Ockenden's team.

Murray said the government is weighing the request and that nothing is "off the table," while noting that affected families themselves are divided on whether a full public inquiry is the right path, even as they're united in wanting accountability and real change.

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What the Trust and the Government Are Promising

NUH chief executive Anthony May and chair Nick Carver issued an open letter to the people of Nottinghamshire apologising "unreservedly" to families who suffered harm, loss, trauma, or distress in the trust's care.

Murray confirmed that Martha's Rule, which gives patients the right to request an urgent second clinical opinion from a separate care team, will now be rolled out to every maternity unit in England, as Ockenden had recommended.

A further measure targets the exact problem the review's own engagement numbers exposed: current and former NHS staff who refuse to give evidence in future maternity inquiries will be compelled to do so, facing up to two years in prison if they still refuse.

Ockenden is already leading comparable reviews into maternity care failings reported by families in Leeds and Sussex, work that suggests Nottingham's findings may not stand alone as an isolated institutional failure.

Key Takeaways

• An independent review led by Donna Ockenden found 520 mothers and babies suffered "potentially avoidable" harm or death at Nottingham University Hospitals NHS Trust between 2012 and 2025.

• The review examined 27 maternal deaths and 31 newborn deaths, finding care failures likely contributed to the outcome in most cases reviewed in depth.

• Nearly 2,500 families and over 800 NUH staff took part in the review.

• The Nottingham Maternity Families group has asked for a statutory public inquiry with the power to compel witness testimony.

• Health Secretary James Murray confirmed Martha's Rule will be implemented at every NHS maternity unit in England.

• Almost half of 66 NUH executives approached for the review declined to engage.

Sources

• The Guardian — 'Horrific' Maternity Care Failings at Nottingham NHS Trust Prompt Calls for Public Inquiry

• West Bridgford Wire — Damning Ockenden Report Sets Out Failures in Nottingham Maternity Care

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