Ockenden report: Clear opportunities were missed time and time again

As a police investigation into maternity failings at the Nottingham University Hospitals NHS Trust, launched in 2025 continues, the findings of senior midwife Donna Ockenden’s review into the Trust have today been published. Around 2,500 families and more than 800 staff contributed. Put simply, what has happened with maternity care at hospitals governed by the Nottingham University Hospitals NHS Trust is a huge national scandal. Yet, what is particularly shocking and distressing here is not just the sheer scale of the failings spanning the period from 2012 to 2025 that resulted in avoidable harm and death, but that clear opportunities were missed time and time again to improve patient safety and to prevent further avoidable harm and death. 62 neonatal deaths, 93 stillbirths, six maternal deaths and 105 cases where babies suffered life changing brain injury were all potentially avoidable.

Donna Ockenden’s report highlights a number of issues, including:

• Failures of leadership, governance and organisational culture, including a failure to listen, investigate concerns and learn from mistakes to improve patient safety and care;
• Serious incidents appear not to have been taken seriously or appropriately reported; many cases lacked incident reports despite clear need, over 100 unreported serious incidents were identified, serious incidents were not formally classified as such, and families were not informed of what had happened. This resulted in missed opportunities to learn and prevent future harm due to a lack of investigation and follow-up. It also denied the families affected a proper explanation as to what had happened, accountability and an apology;
• Chronic understaffing, under-resourcing and sustained operational pressures contributing to failures over many years;
• A toxic culture in which bullying was normalised and vulnerable women’s concerns dismissed;
• Significant inequalities in harm: Black, Asian and minority ethnic women, women with mental health needs, non-English speakers, and women from lower socioeconomic backgrounds were most affected and least likely to have their concerns acted on.

A recent BBC report maintains that a previously unpublished external review by a workplace psychologist dated 30 March 2016 (carried out between December 2015 and March 2016) both praised the commitment of staff, but flagged concerns around “workload, inappropriate behaviour and wider issues with workplace culture”. The workplace review was commissioned to look at culture, identify issues, and provide recommendations for potential solutions. Yet baby Harriet Hawkins was tragically stillborn in 2016, days after the date of the workplace review report. Whilst Harriet’s parents were told she had died from an infection and the Trust initially found “no obvious fault”, alarmingly, an external review into her death identified 13 failings, and found that Harriet’s death was “almost certainly preventable”. Her parents have since spoken of a “toxic culture” at the Trust.

Apparently 49 members of staff, including doctors and midwives contributed to the 2016 workplace review on an anonymous basis. They commented on being under “immense pressure” due to short-staffing, a need to close the labour suite when it became unsafe, newly qualified midwives being assigned high risk cases they were not qualified to manage, senior staff being unsupportive to junior staff and sometimes belittling them and a lack of appropriate equipment including thermometers. Yet what came of this review? Unbelievably, it would appear that lessons were neither learned, nor meaningful action taken to improve the quality of care and safety for mothers and babies when an external workplace review in 2016 flagged the pressing need for both, having identified a number of concerns. Given the implications for patient safety, this is quite staggering and has allowed a toxic culture to become deeply entrenched and systemic whilst unsafe working conditions and practice have become normalised.

Donna Ockenden has said of the 2016 workplace review:

“Absolutely, I am fully aware of those issues and what I would say is that a lot of those issues took a very long time to sort out…”.

“They were not sorted out in 2016 immediately.”

To add insult to injury, the CQC carried out an unannounced inspection of the Trust’s maternity services in 2020, downgrading them to “inadequate”. This followed an inquest into the tragic death of baby Wynter Andrews minutes after she was born, the coroner concluding that there was an ‘unsafe culture’ in one of the Trust’s maternity units. Findings of note by the inspectors, made in 2020 chime with the 2016 workplace review findings and include:

• Women being left at risk of harm due to a shortage of midwives and failings by staff to properly assess women who could be high risk pregnancies or at risk of deteriorating on the ward while in labour;
• Not enough midwifery staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment;
• Incidents not always reported due to the demand on staff and there was ineffective feedback and escalation;
• Not enough suitable equipment available to help staff safely care for women and babies;
• Staff not always risk assessing women appropriately and in line with national and local guidance and records not always being maintained;
• Staffing shortages, with staffing levels not being adjusted to ensure safe numbers of staff in all areas;
• Staff reporting that they were frequently missing breaks and working over their hours as a result of the low staffing levels;
• A lack of open culture in which staff felt confident raising concerns without fear;
• Poor leadership, with a culture of not learning lessons and a lack of leadership skills and abilities to effectively lead the service; and
• Leaders not operating an effective governance process to continually improve the quality of the service and safeguard the standards of care.

Depressingly, this is just one of many scandals afflicting maternity units in England and Wales. The picture nationally is more worrying than ever, showing a marked and concerning lack of progress in improving maternity standards, to the extent that Baroness Amos’ review into maternity care was commissioned by the former health secretary, Wes Streeting, the publication of which is imminent.

The Nottinghamshire scandal exemplifies the huge challenge facing maternity services nationally. There continues to be both a staffing and recruitment crisis in the sector, with serious shortages of obstetricians and midwives. When constantly stretched, stressed and exhausted, maternity staff will simply not have the physical or emotional resources to offer kind, compassionate and competent care and risk becoming desensitised to devastating events, with staff struggling to perform to the required standards in terms of both compassion and safety and training and supervision are also seriously impacted. These conditions result in existing maternity staff becoming burned out and leaving the sector, worsening the conditions for those remaining, making any improvements in maternity care and patient safety practically impossible, whilst effectively deterring new talent from entering the profession.  This is a terrible and inexcusable state of affairs –  birthing mothers and their babies should, at the very least, be entitled to kind, compassionate and competent care during such a vulnerable time in their lives.

To compound an already challenging situation, there is an emerging picture of an institutional inability to learn from such serious failures, as evidenced here in terms of the lack of learning and positive change following not just the workplace review in 2016, but also the highly distressing and heartbreaking experiences reported by the parents and families affected, including Harriet Hawkins’ parents who continue to bravely fight for justice and campaign to stop the same devastating mistakes that caused Harriet’s stillbirth from being repeated and inflicting harm, death, suffering and trauma on other families. Similar issues were reported with regard to maternity services in Leeds only recently – the maternity unit at St James’s University Hospital was threatened with closure if it did not implement an urgent improvement plan, but in spite of this, allegedly babies continued to be harmed.

There has been a systemic failure within the NHS to embrace a culture of openness and transparency and to learn from mistakes to improve standards in patient care. Following the Francis report, commissioned to investigate the widespread failings at the Mid Staffordshire NHS Trust back in 2013, many NHS Trusts promised to prioritise patient safety, embrace the values of transparency and accountability and learn from their mistakes, to ensure they were never again repeated. But since that time, there has been a wave of maternity scandals. Those brave staff who do speak out, as well as the courageous families who report genuine concerns, talk of being ignored – with their concerns being swept under the carpet, when this vital and potentially life-saving information should be carefully considered and used to inform and improve patient care and safety. In an NHS setting, mistakes can cause harm and cost lives. Why is more not being done to learn from these mistakes and to avoid them from ever being repeated again? In the wake of an aeroplane crash, great attempts are made to salvage the black box from which valuable data is retrieved so that vital learning can take place to ensure such a disaster is never again repeated. But in the sphere of maternity services, where failings can result in heartbreaking, traumatic and life-changing loss and harm, lessons are just not being learned. With such entrenched and systemic problems, it is very hard to see how confidence can be restored to a sector in crisis.

It is positive that Martha’s Rule, which allows families to seek a second urgent opinion if they’re concerned about the care their loved ones receive, will now be extended across all maternity settings in England. Additionally, Donna Ockenden has made a range of sensible recommendations, including:

• • Listening to women and families
  • Workforce planning and safe staffing
  • Training and multidisciplinary learning
  • Risk assessment throughout pregnancy
  • Incident investigation and family involvement
  • Governance and board accountability
  • Culture, teamwork and psychological safety
  • Care for mothers who have died and post-death care.

The effective implementation of the sensible measures recommended by Donna Ockenden will require not only huge structural and cultural change from top down, but also a significant investment in staffing, training and supervision. Without this, it is sadly inevitable that more mothers and babies will be at risk of avoidable harm and death and the suffering and heartbreak of those families impacted by the widespread and systemic failings at the Trust will be utterly in vain.