Lead

More than 500 mothers and babies suffered potentially avoidable harm or died as a result of poor care at Nottingham University Hospitals NHS Trust, according to an independent inquiry whose findings were published on Wednesday. The review, led by senior midwife Donna Ockenden, examined 2,500 cases involving mothers and babies who died or were seriously injured, or babies who were stillborn, while under the care of the trust between 2012 and 2025. The report found that failures in maternity and neonatal care were "systemic, deep-rooted and sustained over many years."

The inquiry detailed that 444 women and 76 newborn babies suffered "potentially avoidable" outcomes, with at least 156 cases involving the death of babies and six maternal deaths. The trust operates two maternity units: Queen's Medical Centre and Nottingham City Hospital. The report described a "bullying and toxic culture" at these units, where staff did not listen to women's concerns and did not act promptly on them, and where senior leaders were repeatedly warned about serious problems but failed to take effective action.

Coverage Comparison

The findings were reported by multiple outlets, each with a slightly different focus. Al Jazeera reported the inquiries into maternal and neonatal deaths in England, noting that the Nottingham report was one of two new inquiries that found substandard care contributed to a rise in maternal and neonatal deaths. The outlet highlighted that the UK maternal mortality rate for 2022-2024 was 12.8 deaths per 100,000 maternities, a rate 20% higher than 2009-2011, and that the rate among black women was nearly three times higher than that of white women.

Dawn focused on the "bullying and toxic culture" at the trust and the failure of senior leaders to act on warnings. The Guardian's coverage emphasized the scale of the scandal, with one article noting that the report described failings that were "horrific" and "chilling," according to health secretary James Murray. The Guardian also covered the appointment of a national maternity commissioner, announced in response to a separate review of maternity care led by Baroness Valerie Amos, and the criticism of that appointment from a bereaved mother who founded a maternity safety campaign group.

Key Claims

  • More than 500 mothers and babies suffered potentially avoidable harm or died due to poor care at Nottingham University Hospitals NHS Trust, as reported by multiple outlets.
  • The trust's maternity units were found to have a "bullying and toxic culture," with staff not listening to women's concerns and failing to act promptly.
  • The report identified that women and families were consistently ignored when they raised concerns, and that delays in scans and a lack of pain relief contributed to harm and deaths.
  • The UK maternal mortality rate for 2022-2024 was 12.8 per 100,000 maternities, a rate 20% higher than in 2009-2011, according to an Oxford University study, as reported by Al Jazeera.
  • The rate of maternal deaths among black women was nearly three times higher than that of white women, as reported by Al Jazeera.
  • A maternity commissioner is to be appointed, as announced by health secretary James Murray in response to the Amos review, which concluded that the maternity and neonatal system in England is "no longer fit to consistently deliver high-quality, compassionate care" and requires urgent reform.
  • The Amos review also found racism and discrimination embedded throughout the maternity and neonatal system, as reported by The Guardian.
  • Bodies in the mortuary at Nottingham University Hospitals NHS Trust were found in a state of "advanced deterioration" due to not being transferred to a freezer in time, as reported by The Guardian.

Perspectives

Government/Health Secretary

The health secretary, James Murray, described the failings as "horrific" and "chilling," stating that families suffered "dangerously and tragically deficient care at almost every turn" and that the NHS failed them catastrophically. He announced the appointment of a national maternity commissioner in response to the Amos review, a role that will pursue hospitals over persistent failures in care and ensure wide-ranging improvements are made.

Bereaved Mother and Campaigner

Emily Barley, a bereaved mother whose daughter died due to failings at Barnsley hospital, criticized the appointment of the commissioner, calling it "fundamentally dangerous" and "insane" to concentrate power in one person. She argued that the move seems designed to "grab headlines" rather than make real change, and she repeated her call for a public inquiry into maternity care failings. The Nottingham Maternity Families group also asked Prime Minister Keir Starmer to establish a statutory public inquiry into failures across the entire NHS.

Report Authors

Donna Ockenden, the senior midwife who led the Nottingham inquiry, reported a "bullying and toxic culture" and found failures that were "systemic, deep-rooted and sustained over many years." Valerie Amos, who authored the separate review, concluded that the system is "no longer fit to consistently deliver high-quality, compassionate care" and requires urgent reform.

Expert Adviser Disagreement

Dr Bill Kirkup, a maternity safety expert and one of the 12 expert advisers to the Amos review, claimed that the final report was altered to remove criticism of "normal birth ideology." He said he resigned because he disagreed with the removal, arguing it was a "patient safety danger" that should be "called out." The Amos report itself states that Kirkup decided to stand down because he could not agree on the specific wording of conclusions on normal birth ideology.