The painful familiarity of key themes in Donna Ockenden’s review of maternity care failures must not detract from the urgency around this issue. The 400-page report published on Wednesday is a shocking catalogue of what went wrong at Nottingham university hospitals NHS trust. Its contents range from a excruciating case study of the errors leading to the death of baby Harriet Hawkins in 2016 – and the cover-up that followed – to trust-wide problems with staffing, culture and leadership. It also highlights flaws in the wider NHS, citing the finding of the 2022 Messenger review that political pressure can lead bosses “to look upwards to furnish the needs of the hierarchy rather than downwards to the needs of the service-user”.
Donna Ockenden. Photograph: Peter Flude/The Guardian
Given its around 100 action points, implementation is a daunting prospect. Next week, Valerie Amos will add to these, and the more than 700 recommendations of earlier reports, with her own investigation of maternity care in England. Wes Streeting had pledged to chair a new taskforce and his resignation as health secretary alarmed campaigners. Whoever ends up in charge, a commitment to maternity care improvement must be non-negotiable, and firmly grounded in practicalities. The review points to a damaging split between strategy and operations in Nottingham. NHS England must avoid replicating this.
Safe staffing emerges as a crucial factor, with nine in 10 midwives reporting wards as understaffed. Experts including Prof Alison Leary, deputy president of the Royal College of Nursing, believe that minimum nurse-patient ratios should be set out in law. But workforce shortages were not the only problem. One of the most challenging findings is how long poor services continued, with a change of leadership in 2017 arguably making matters worse. The review identifies a 2006 merger as one cause of later failures. Two separate maternity units operated in silos with insular and sometimes toxic cultures, a familiar pattern of poor communication between doctors and midwives, and deeply troubling incidents of racism.
Nottingham paid fines totalling almost £2.5m in 2023 and 2025, following Care Quality Commission investigations into failures in the care of babies including Wynter Andrews. A police inquiry, Operation Perth, is considering corporate manslaughter charges and has made two arrests linked to mortuary services. Mrs Ockenden herself is booked to lead two further investigations, in Leeds and Sussex. But with Nottingham campaigners rightly furious at the lack of cooperation from senior NHS leaders, many of whom refused to give evidence, some argue that these local, expert-led investigations are not enough. They want a statutory public inquiry instead.
Yet it is not clear that another years-long inquiry with an even wider remit would serve the public interest. The families failed by the NHS in Nottingham, and elsewhere, deserve anger on their behalf as well as sympathy and gratitude. But there is no guarantee that further examination of past mistakes would lead to the improvement that must be the priority, at a time when maternal deaths have climbed to a 20-year high, and the worse outcomes for black, minority-ethnic and economically deprived mothers are disturbingly apparent.
What is needed urgently is a response from ministers to recommendations including a new standard for perinatal care, and a plausible plan to raise standards. The devastating neglect revealed in this report must never be repeated.
