A senior medical negligence solicitor has urged healthcare leaders to ensure lasting improvements to maternity care following the publication of the Ockenden Review into services at Nottingham University Hospitals NHS Trust (NUH).
Claire Cooper, Senior Associate Solicitor at Rothera Bray specialising in medical negligence, said the long‑awaited report marks a “pivotal moment” for the thousands of families affected, but warned that its true impact will depend on how its findings are implemented.
The independent review, led by Donna Ockenden, examined maternity care provided by NUH between 1 April 2012 and 31 May 2025. It forms part of a wider national effort to address patient safety concerns and improve outcomes for mothers and babies across the NHS.
Initially expected to consider around 1,700 cases, the review expanded significantly, with approximately 2,500 families included, making it the largest maternity investigation ever undertaken within the NHS.
Mrs Cooper said the scale of the review reflects the seriousness of the concerns raised.
“Many families have shown immense courage in speaking out about their devastating experiences, and the release of this report is deeply emotional and incredibly important. Our thoughts are with all families included in the review, as they are with all families affected by substandard maternity care across the country. Families need to know that their experiences will lead to change. That means better communication, safer systems and a culture that listens to concerns and acts on them.”
The review examined cases across five key categories:
Stillbirths from 24 weeks gestation
Neonatal deaths (up to 28 days after birth)
Babies diagnosed with hypoxic ischaemic encephalopathy (HIE) and other serious hypoxic injuries
Maternal deaths
Severe maternal harm, including major haemorrhage, intensive care admissions, eclampsia, pulmonary embolus, and emergency surgical procedures
The review team, made up of experienced clinicians and independent experts, assessed whether care met expected standards and whether improved care may have led to different outcomes.
The Ockenden Report
Timeline of Concerns
The Report confirms concerns about NUH Trust were raised from as early as 2007:
Indicators of risk were identified from as early as 2007 including issues with incident management, workforce capacity, leadership and organisational culture.
External reviews went on to identify a continuation of these issues in 2015 and 2016 but the organisation’s response limited the change that could have been made.
Despite continuing concerns Serious Incidents continued between 2017 to 2019.
A systemic failure was occurring by 2020 and 2021 and serious concerns were identified by the CQC and Healthcare Safety Investigation Branch including persistent concerns relating to safety, leadership and culture. National intervention was commenced.
In 2022 a regional review was terminated following concerns about the credibility and effectiveness of the NUH Trust’s oversight processes and the independent Donna Ockenden Inquiry was commenced.
24 June 2026 the Ockenden Report is published.
NUH Trust key concerns
Within the Ockenden Report there is a letter from Donna Ockenden to the Secretary of State for Health and Social Care, confirming some of the specific concerns relating to NUH Trust:
“Insufficient staffing and funding across perinatal care settings”
“The inability of staff to undertake even basic (often, mandatory) training”
“Persistent failure to listen to and believe mothers and fathers”
“Corresponding failure to investigate, and therefore learn from mistakes.”
“Both mothers and staff ‘on the ground’ in Nottingham have reported... being bullied by a small minority of powerful leaders who had been allowed to ‘infect’ the unit.”
Calls for accountability
Donna Ockenden powerfully concluded in her letter to The Secretary of State for Health and Social Care,
“I firmly believe that safe, compassionate and equitable perinatal care is still achievable in Nottingham and across England, but only if there is unwavering commitment to accountability, learning, transparency and kindness at every level of the system. We owe it to every mother, every baby and every family whose terrible experiences are recorded here that they are never repeated. Now is the time for focused, collective action to ensure sustained improvement that will allow every woman in England to have confidence in the care that they will receive when giving birth in the NHS.”
Operation Perth is a separate investigation by Nottinghamshire Police relating to the maternity treatment provided by NUH. NUH was confirmed in May 2025 to be subject to a corporate manslaughter investigation, which continues.
Two men were also arrested on suspicion of misconduct in a public office on Monday 22 June in connection to Operation Perth. Nottinghamshire Police have confirmed they have identified “breaches of regulations of the Human Tissue Act in relation to the management and operating practices of the mortuary services”.
Ian Johnson, Head of Clinical Negligence at Rothera Bray LLP said, “After nearly 4 years of enquiries it is welcome that the report of Donna Ockendon has now been published. The scale of the failings in NUH NHS Trust is almost impossible to comprehend. So many families from Nottinghamshire and beyond have had their lives changed for ever, which were entirely preventable. The refusal of some former senior leaders at the Trust to take part in the review makes it imperative that a full statutory public inquiry is established so they and others may be compelled to give evidence if they do not agree to do so voluntarily.”
Greg Almond, Partner and Head of Serious Injury and Public Inquiries at Rothera Bray LLP commented: "Given the scale of the maternity crisis across the country not just in Nottingham or Leeds, it is clear that the Government should now order a full national, Judge led, statutory Public Inquiry – these piecemeal reports are not sufficient. The new Prime Minister must make this a priority.”
Moving forwards: The Ockenden Report Immediate and Essential Actions
The Ockenden report has recommended both Local Actions for Learning (LAfLs) and England-wide Immediate and Essential Actions (IEAs). Donna Ockenden has advised for these to be “swiftly implemented at the Trust and across the wider perinatal system in England.”
All recommendations include the overarching principle of Martha’s Rule: In both clinical and community settings women, families, and staff must be allowed to request an urgent additional clinical review if they have ongoing concerns.
18 IEAS have been set out as follows:
Strengthening women-centred communication and informed choice
Support a nationally agreed perinatal workforce planning methodology as a critical enabler of perinatal improvement at pace and scale
National IEA for Labour Ward Coordinator Role
All Trusts must support Training for Midwives in the use of Speculum Examination
Enhanced Maternal Care
Delivering Safe, Personalised and Equitable Maternity Care through early risk recognition, coordinated care and responsive services
National standard for standardisation and recording of fetal growth risk assessment
There must be a national standard and documentation for maternity triage and record keeping in maternity care provision
Support the development and implementation of a structured assessment framework for the latent phase of labour, ensuring clarity when the “latent phase of labour” becomes abnormal and requiring escalation
All Trusts must define criteria for the safe use of telephone postnatal follow up, indicating when telephone follow up is acceptable or when face to face follow up is mandatory.
National standard for obstetric anaesthetic record-keeping
Safe, accessible and comprehensive maternity anaesthetic documentation
DHSC/NHSE should introduce and support access to coordinated multidisciplinary debrief and psychological support
Funding for implementation of Maternity Patient Safety Incident Reporting Framework (PSIRF)
Strengthened multidisciplinary governance and learning
Foster a compassionate, psychologically safe, and learning culture
DHSC/NHSE should recommend and support recruitment processes and implement a consistent onboarding package for new starters
All Trusts to ensure compliance, audited annually, with the NHS Records Management Code of Practice (2023).
Mrs Cooper said the publication of the findings must act as a catalyst for real and sustained change within maternity services.
“While the report is a crucial step in acknowledging what has happened, there must now be a clear commitment to learning from these findings and ensuring that improvements are embedded in practice - not just in Nottingham, but across the NHS. I sincerely hope that there will be significant national improvements in transparency, accountability and most importantly the care for mothers and babies.”
Next steps for families
Families involved in the review will receive individual feedback reports, with cases graded as:
0 – Appropriate
1 – Minor concerns
2 – Significant concerns
3 – Major concerns
These reports are being issued from late June 2026 through to the end of December 2026. Families will also have opportunities to ask questions and provide feedback directly to the review team.
Those whose cases involve maternal death or are graded as significant or major concerns will be offered meetings to discuss their findings in more detail.
Mrs Cooper commented that while the review provides important answers, many families may still be considering their next steps.
“For some, the findings may raise further questions about whether their care fell below acceptable standards. Independent legal advice can help families understand their options and whether they may be entitled to pursue a claim.”
“We understand the profound and lasting impact that poor maternity care can have. It’s essential that families are supported holistically, including being signposted to specialist organisations and services that can help them process what they have experienced.”
As attention now turns to how the findings will be implemented, Mrs Cooper emphasised that the ultimate goal must be improved safety for future patients.
“The publication of this report must mark the beginning of meaningful change. The hope is that lessons are truly learned, accountability is upheld, and that safer care becomes a reality for all families using maternity services.”
For more information about Rothera Bray Solicitors, visit: https://rotherabray.co.uk/
Press contacts:
Susan Wilkinson – Marketing Manager
s.wilkinson@rotherabray.co.uk
T: 07584 260803
Claire Morrison – Marketing & BD Coordinator
c.morrison@rotherabray.co.uk
