A damning independent review has found that 520 mothers and babies suffered potentially avoidable harm or death due to catastrophically poor maternity care at Nottingham University Hospitals NHS Trust (NUH) in central England — the largest maternity inquiry in the history of the National Health Service. The report, published on 24 June, concluded that 444 women and 76 newborns received dangerously substandard care across two hospitals — Queen's Medical Centre and Nottingham City Hospital — in cases spanning more than a decade, from 2012 to 2025. Among the most severe outcomes were 94 stillbirths, 62 neonatal deaths and the deaths of six mothers.

The 401-page report was authored by Donna Ockenden, a respected maternity safety expert appointed to lead the review in 2022 after families raised alarms about unsafe care. Drawing on testimony from more than 2,500 families and 838 current and former staff, Ockenden painted a stark picture of a trust defined by chronic understaffing, a "bullying and toxic culture" driven by "intimidating cliques", repeated failures to monitor babies during labour, and a systemic pattern of dismissing women's concerns. Staff frequently failed to escalate worrying cases to doctors, misread foetal monitoring traces, and in some instances denied women adequate pain relief. One mother was told to "take some paracetamol and have a hot bath" when she raised concerns. A baby girl who died early in gestation was inadvertently disposed of as clinical waste following her post-mortem, compounding her family's grief. Ockenden concluded that trust management and senior NHS leaders were repeatedly warned about these problems and failed to act, and that the institution was determined to conceal the dangerous reality of its maternity units from public view.

The human stories behind the statistics have drawn widespread attention. Sarah and Jack Hawkins — both clinicians at the trust at the time — lost their daughter Harriet to a stillbirth in 2019 that Ockenden described as avoidable and "compounded by a systemic cover-up". The couple said their concerns were dismissed and they were not told the truth even after Harriet's death, calling the inquiry's conclusion the end of a "relentless and at times almost unbearable ten-year campaign". Gary Andrews, whose daughter Wynter was born after her parents were wrongly advised in 2019 to terminate what was in fact a healthy pregnancy, recalled being told by a clinician that "if we listened to every mother's concerns, we'd be overrun". Health Minister James Murray described the findings in parliament as "horrific" and "chilling", saying the NHS had "failed these families catastrophically" through "neglect, incompetence, racism, discrimination, contempt and harassment".

The scandal has intensified pressure on the government and health authorities to move beyond inquiry and into lasting reform. The Nottingham Maternity Families group, representing around 600 harmed and bereaved families, has called on Prime Minister Keir Starmer to establish a statutory public inquiry with the power to compel witnesses — a request the government says it is considering but has not yet committed to. Murray announced that "Martha's Rule" — which gives patients the right to request an independent clinical assessment — will be extended to every maternity unit in England, and that NHS staff who refuse to cooperate with future maternity inquiries could face up to two years in prison. Almost half of the 66 NUH executives invited to engage with Ockenden's review declined to do so, a refusal families described as "appalling".

For analysts and campaigners, the Nottingham report is the latest in a long line of NHS maternity reviews — following inquiries into Morecambe Bay, Shrewsbury and Telford, and East Kent — that have identified almost identical failures: too few staff, poor clinical leadership, defensive institutional cultures and women being systematically ignored. The Royal College of Midwives reports that 45% of midwives experience burnout often or always, and only 16% feel staffing levels are adequate. With maternity care accounting for 51% of the NHS's entire clinical negligence bill — approximately £2.5 billion in 2024-25 — experts warn that publishing reports is not the same as delivering change. As Ockenden herself is already leading similar reviews in Leeds and Sussex, the central question is no longer what is going wrong in NHS maternity care, but whether this time the findings will finally translate into action.