Largest maternity review in NHS history published, revealing widespread failures

The largest maternity inquiry in the history of the NHS has been published, outlining widespread failings in care at Nottingham University Hospitals NHS Trust. The report, led by senior midwife Donna Ockenden, investigated 2,500 cases of stillbirths, neonatal deaths, maternal deaths, and brain injuries occurring between April 2012 and May 2025.

The findings, presented at a press conference in Nottingham, are expected to detail a catalogue of appalling behaviour including racism towards mothers. Paula Sussex, the parliamentary and health service ombudsman, said the report "adds to an overwhelming body of evidence that maternity services are failing women and families in ways that are repeated and preventable." She highlighted persistent issues: failures in communication, not listening, delays in diagnosis, and poor postnatal care.

Labour MP Michelle Welsh, the government's first maternity adviser, said it was "pure luck" that her own baby survived and called for huge systematic change rather than "tinkering around the edges." Nottinghamshire police are still considering corporate manslaughter charges against the trust. On Monday, two men were arrested in connection with mortuary service practices.

Among the families affected, Sarah and Gary Andrews lost their daughter Wynter in 2019 after staff failed to perform a timely caesarean section. Sarah described being told to stay at home for six days during labour and then experiencing "truly horrific" hospital care. Despite clear signs of infection, staff did not listen to her concerns, and resuscitation attempts failed. One staff member reportedly said, "If we listen to every mother’s concerns, we’d be overrun."