Donna Ockenden Review into Maternity Services – Nottingham University Hospitals NHS Trust.

On 24 June 2026 the finalised report by Donna Ockenden was published. This report followed an independent review into failings in maternity and neonatal care at Nottingham University Hospitals NHS Trust (NUH).

The inquiry is the UK's largest ever carried out with around 2,500 families' experiences considered, spanning care provided between 2012 and 2025. The review comes after numerous instances of baby deaths and injuries at the Trust and following Donna’s inquiry into maternity services at The Shrewsbury and Telford Hospital NHS Trust (SaTH).

The review was a colossal undertaking, covering instances of stillbirth, neonatal deaths, brain damage to the baby, harm to mothers and maternal deaths. The sheer amount of families involved highlights the magnitude of the problem. An inquiry of this scale, so close after her inquiry at SaTH and similar reviews in Wales at Cwm Taf Morgannwg and Swansea Bay University Health Boards, paints a stark picture of the condition of the nation’s maternity services and the desperate need for uniformed change.

The review, pushed for by an initial group of united families, who had all experienced harm or bereavement at NUH, was published on 24 June 2026 and found that, sadly, many of the issues described were known to NUH since at least 2010 and included issues with staffing, non-compliance with mandatory training, lack of funding for services and importantly a reluctance to listen to parents and their concerns. The failure to adequately investigate created the inability to learn from past mistakes.

As with her previous inquiry, Donna’s team graded the cases from 0 – 3 with Grade 0 meaning that appropriate care was provided, in line with best practice. And there being major concerns and suboptimal care for those cases grade a 3, often meaning that different management would reasonably have made a different to the outcome.

Across the entire review 444 maternity cases and 76 neonatal cases were graded either a 2 or 3. 27% of cases reviewed fell into a category where the care was considered to have been suboptimal. 50% of the cases concerning babies surviving, but suffering a hypoxic injury were graded a 2 or 3 and just over 21% of the maternal deaths considered were found to have had suboptimal care. Over 68% of the cases reviewed that concerned maternal harm, for example fourth degree tears, obstetric haemorrhages and severe pre-eclampsia, were graded in the worst categories. These are sobering figures.

The inquiry highlights common themes amongst the concerns including;

• Issues with triage,
• Escalation issues often failures to escalate to senior clinicians,
• Delays in assessments and transfers (especially within neonatal care)
• Failures in fetal heart rate monitoring, CTG interpretation and recognition of fetal compromise,
• Poor multidisciplinary communication,
• Failures to recognise the evolving risk during labour and birth and,
• Failures with postnatal monitoring, observations and risk.

It is difficult to see where we go from here. The failings identified echo those found within the SaTH review and other maternity reviews, demonstrating that these issues are engrained within our NHS services and culture nationwide. Perhaps the most concerning is the reluctance to listen to women when they are particularly vulnerable, entrusting not only their care but their baby’s care to our NHS. Whilst the review did highlight some excellent examples of maternity and neonatal care, they must be the many and not the few.

Overall, we hope that the significant and bleak failings in the Nottingham Inquiry helps to identify past mistakes, rebuild trust within the local community, and ensure that all affected families – past and future - have a voice in the maternity process. The goal is to learn from these incidents and make substantial improvements to maternity services nationally, with the ultimate aim of preventing similar tragedies in the future.

Our thoughts are with the thousands of families who entrusted Donna and her team with their personal accounts. Their willingness to be so brave in the face of such tragedy and personal loss in order to drive change across our maternity services is monumental and above all, selfless.

If you wish to speak to our specialist maternity team, please email: info@lblaw.co.uk or phone 0800 652 3371.