A major independent review led by Donna Ockenden has identified serious and repeated failings in maternity services at Nottingham University Hospitals NHS Trust, following one of the largest maternity investigations ever undertaken in the NHS.
The review examined care over a prolonged period and drew on evidence from more than 2,500 families, alongside extensive engagement with staff and detailed analysis of clinical records. It concludes that the issues identified were not isolated incidents, but part of wider and recurring systemic problems within maternity services.
The final report was published on 24th June 2026.
At the centre of the report are eight key areas for urgent improvement, which set out what must change to improve safety, accountability and the experiences of women and families.
These are:
- Listening to Women & Families
- Workforce Planning & Safe Staffing
- Training & Multi Professional Learning
- Risk Assessment Throughout Pregnancy
- Incident Investigation & Family Involvement
- Governance & Board Accountability
- Culture, Teamwork & Psychological Safety
- Mothers Who Have Died and Post Death Care
The report emphasises that failures across these areas contributed to repeated breakdowns in care and a lack of consistent learning from incidents. It highlights the importance of ensuring women’s concerns are listened to, properly escalated and acted upon throughout pregnancy and birth.
It also stresses that staffing pressures, training gaps and weaknesses in leadership and governance all played a role in the failings identified, alongside issues in workplace culture and team communication.
Families were central to the review process, with more than 2,500 contributing their experiences to help inform the findings and recommendations.
The publication of the report brings the Independent Maternity Review to a close and sets out a framework for change intended to improve maternity safety and prevent similar failings from recurring.
Source: Ockenden Maternity Review
