The largest maternity inquiry in the history of the NHS has revealed a catalogue of errors spanning many years, resulting in the deaths of dozens of babies and significant harm to hundreds of others.
More than 2,500 families and over 800 members of staff contributed to the inquiry, which found there were 62 neonatal deaths of babies overall. Assessors discovered that babies died from a range of conditions, including oxygen starvation, mismanaged labour, hospital-acquired infections, and poor postnatal care delivered by midwives and doctors.
The inquiry, led by senior midwife Donna Ockenden, found that there were 'potentially avoidable' outcomes relating to 444 maternity cases examined up to May 2025, alongside 76 neonatal cases. Experts concluded that 31 reviews into baby neonatal deaths at the trust included potentially avoidable harm at grades 2 and 3, with at least eight of these babies potentially having survived.
Leadership instability, bullying, and a 'toxic culture' were identified as major contributing factors affecting the quality and safety of maternity services. Between 2017 and 2021, there was 'sustained turnover in senior maternity leadership positions' and senior operational roles.
The review team also found that staff were reluctant to escalate concerns and transfer to the labour ward 'due to professional cultures', resulting in delays in recognition and escalation of postpartum haemorrhage, as well as major obstetric haemorrhage, causing women harm.
Managers at the trust were often thought of as 'invisible, unapproachable, and unresponsive' and ignored concerns, bullied people, and were rude and aggressive. Staff shortages and operational pressures affected all areas of maternity, with staff describing routinely working 'beyond safe capacity'.
The review also examined 17 babies and one adult who died and what happened to them after death, finding 'recurring examples of failure to protect the dignity of the deceased, including an early gestation baby disposed as clinical waste.'
Health Secretary James Murray pledged to 'deliver lasting change', adding that lessons from Nottingham would form part of the national plan to deliver real improvements in maternal and neonatal care for all families.
The Department of Health and Social Care said that Martha's Rule will be extended to all maternity settings in England, allowing parents to request a rapid review if a baby or mother's condition is deteriorating and they are concerned staff are not responding to this.
NUH trust chairman and chief executive apologised in an open letter, saying while improvements have been made, there is more to do, and apologising unreservedly to the women and families who have suffered harm, loss, trauma, or distress while receiving care in their services.
