Ockenden’s Final Report Into Maternity Services At Nottingham University Hospitals NHS Trust – 24 June 2026

Donna Ockenden’s final report into maternity services at Nottingham University Hospitals NHS Trust has been published.

This is the largest single review of its kind in NHS history, examining more than 2,500 cases from 2012 to 2025. It follows years of families bravely sharing their experiences of loss, injury and trauma.

At the national level, Baroness Valerie Amos’s independent investigation continues its work, with its February 2026 interim report already underlining the pressures facing services across England.

At Bond Turner, we represent families across the country who have suffered life‑altering harm in maternity and neonatal care. We see the human reality behind these reports every day. Our role is not to sensationalise, but to listen, investigate thoroughly with leading experts, and secure the compensation and answers that can make a practical difference to families facing cerebral palsy, brain injury, stillbirth, maternal complications or other serious outcomes. We understand that no amount of money can undo the harm, but it can fund the care, therapy, adapted housing and support that allows families to move forward with dignity.

The Chronology: What Has Been Examined, Recommended, and (Sometimes) Implemented

The modern wave of focused scrutiny of maternity care began in earnest with Dr Bill Kirkup’s Morecambe Bay Investigation (report published March 2015). It examined a cluster of maternal and neonatal deaths at Furness General Hospital and identified a “lethal mix” of clinical shortcomings, dysfunctional team cultures, governance failures and regulatory oversights. The report made 44 recommendations.

Baroness Julia Cumberlege’s Better Births National Maternity Review (commissioned March 2015, report published February 2016) offered a more aspirational, woman‑centred vision. It called for personalised care, continuity of carer, informed choice and integrated Local Maternity Systems, while setting ambitious safety targets, including halving stillbirths, neonatal deaths and brain injuries.

Alongside these headline reviews, several national programmes were established to provide continuous learning and oversight. MBRRACE‑UK (established around 2013, with ongoing annual reports) and the RCOG’s ‘Each Baby Counts’ programme (launched 2015) have both consistently identified avoidable factors, recurring clinical issues, and persistent inequalities in outcomes.

Following Better Births, the Maternity Transformation Programme (from 2016 onwards) introduced Local Maternity Systems and national datasets to benchmark performance across services.

From 2017, the Healthcare Safety Investigation Branch (now HSSIB) began conducting independent, system‑focused investigations into serious maternity incidents, particularly cases involving neonatal death and brain injury, with an emphasis on learning rather than blame.

Prevention of Future Deaths reports, issued by coroners, have continued throughout this period, frequently highlighting failures in escalation, communication and timely intervention. Their recurrence over time reflects the persistence of known risks.

From 2019, NHS Resolution introduced the Early Notification Scheme and Maternity Incentive Scheme, designed to support earlier investigation of serious incidents and link funding to safety improvements.

Taken together, these initiatives have created a substantial infrastructure for identifying risk and driving improvement. They have consistently pointed to the same themes. The difficulty has not been in identifying the problems, but in embedding the learning.

Sir Robert Francis’s work (Mid Staffordshire Public Inquiry report 2013, Freedom to Speak Up review published February 2015) supplied the broader cultural framework, leading to the statutory Duty of Candour (2014) and Freedom to Speak Up Guardians.

Donna Ockenden’s review of Shrewsbury and Telford (commissioned 2017) produced an interim report in December 2020 and a final report in March 2022. It examined 1,486 families and found repeated failures in listening to women, clinical care, staffing, training and governance, issuing both local and national actions.

Bill Kirkup’s East Kent review (“Reading the Signals,” commissioned February 2020, report published October 2022) found that outcomes could have been different in nearly half the cases reviewed, with many deaths and brain injuries potentially avoidable.

In 2023, the Thirlwall Inquiry was established to examine events at the Countess of Chester Hospital. While distinct in its facts, it reflects the same underlying concerns about escalation, culture and oversight in neonatal care.

NHS England’s Three Year Delivery Plan for Maternity and Neonatal Services (published 2023) sought to embed learning from the above through workforce support, surveillance and inequality reduction. 

Following the post-COVID recovery period and the change of government, longer-term strategic thinking gained renewed momentum. This culminated in the development of a new 10 Year Plan for the NHS and the publication of an updated Women’s Health Strategy in April 2026, which sought to situate maternity care within a broader, system-wide approach to women’s health, with a stronger focus on addressing persistent inequalities and improving outcomes across the life course. 

The Maternal Care Bundle (MCB), published by NHS England in January 2026, is a national framework setting out minimum best-practice standards that all NHS maternity providers must implement by March 2027 (referenced at page 329 of the Ockenden Nottingham report).

Baroness Valerie Amos’s national investigation (commissioned August 2025) takes a whole‑system view. Its interim report (26 February 2026) highlighted families feeling disregarded, long waits, defensive cultures, discrimination, infrastructure problems and workforce strain amid rising complexity.

The chronology matters because it shows that the problems identified in the Nottingham report are not new. Over more than a decade, repeated reviews, investigations and national programmes have identified similar themes: failures to listen to women and families, delays in escalation, poor communication, staffing pressures, governance failings and difficulty embedding learning.

Today’s Nottingham Ockenden final report (24 June 2026) adds detailed findings from over 2,500 cases, expected to address avoidable harm, understaffing, cultural issues and the experiences of women and families.

Ms Ockenden’s Recommendations (24/6/26) and Commentary

Ms Ockenden has made several recommendations for Local Actions for Learning (LAfLs) and England-wide Immediate and Essential Actions (IEAs) and states that these should be implemented swiftly. She summarises that, ‘the overarching principle is that women, families and staff must be able to seek urgent additional clinical review by utilising Martha’s Rule; women must be at the centre of clinical communication and informed decision-making; and there must now be standardisation of national assessment and escalation processes across perinatal care’.

Ms Ockenden notes the pledge made in 2015 to reduce the rate of stillbirths, neonatal and maternal deaths in England by 20% in 2020 and 50% by 2030. It is noted that whilst there are currently fewer stillbirths, they are still above pre-pandemic levels, and maternal deaths are at a 20-year high.

Ms Ockenden also comments on the cost of maternal clinical negligence claims to NHS Resolution. She points out that, ‘Whilst these figures are substantial, behind them is the incalculable effects –financial, physical, emotional and psychological – on the families themselves, with many careers and relationships shattered by what they experienced at NUH’.

Reflecting on the progress that has been made since her previous report (regarding The Shrewsbury and Telford Hospital NHS Trust in 2022), Ms Ockenden notes that many of the 22 IEAs she outlined remain unactioned and may have now become more challenging to implement. She, however, continues to support the previously outlined IEAs and notes that at the centre of all of them is ‘listening to the voices of women and families and all staff working in perinatal services, and more importantly believe what they are saying. If a woman tells a member of staff that she has any concern regarding her own health and wellbeing or that of her unborn/born baby, those concerns must be recorded and appropriate and timely action taken.’

There are 18 IEAs in total in the Nottingham report, but it reiterates the importance of listening to women and families, as the first IEA is – IEA 1: Strengthening women-centred communication and informed choice. Within her comments on this IEA, Ms Ockenden recommends that a mandatory ‘Listen to the Woman and consider her preferences’ assessment field be included within triage and telephone triage documentation. This is an excellent suggestion, as many clients have reported to us that they have contacted the Hospital with concerns and felt that they were not listened to and/or they later found out that their concerns were not correctly recorded.

The remaining IEAs focus on workforce planning, staffing, training, risk assessment standards and documentation, record keeping, incident investigations, governance and board accountability and culture. There are very specific and detailed recommendations under each IEA heading. The recommendations that stand out are:

• By 28 weeks’ gestation, all women must receive a minimum standard set of information on labour and birth, including pain relief options and information about anaesthesia for operative and instrumental delivery. This must include balanced discussions about interventions such as caesarean birth and epidural analgesia, ensuring women are fully informed, supported to make choices that reflect their preferences, and able to develop realistic expectations of their care. This is something that will be very helpful in ensuring that all women feel informed and able to make time-sensitive decisions during birth. It aligns closely with the principles in Montgomery v Lanarkshire Health Board [2015] UKSC 11 on informed consent.
• When postnatal women are medically fit for ‘step down’ from critical care, this must be to an appropriate maternity area, depending on their clinical needs. If ‘step down’ directly to the postnatal ward is considered appropriate, then additional support should be provided for at least the first 24 hours, both to help the woman adjust to her changing circumstances, and to help her care for her newborn baby. The expectation is that the additional support will generally be 1:1 support, which can be provided by a Maternity Support Worker (MSW) or Health Care Assistant (HCA). This will allow women to feel supported at a time when their health needs are often overlooked, whilst they care for their baby.
• Implement a nationally recognised Labour Ward Coordinator (LWC) programme for all Band 7 LWC midwives undertaking the LWC role. The LWC role was highlighted within the Shrewsbury report as a specialised job role, and the training required for this role is now being re-enforced.
• Ensure that, where additional risk factors for maternal or fetal compromise are present, a lower threshold for admission is applied, with senior clinical review and consideration of Electronic Fetal Monitoring (EFM). This will require good record keeping (addressed later in a number of the recommendations) to ensure that triage teams are aware of the relevant medical history.
• Trusts must develop a robust method of training for midwives providing triage care. This must include minimum competency standards for telephone risk assessment, agreed pathways for mandatory attendance for review and a holistic review of physical, mental and social wellbeing assessment. Triage teams are often the first port of call when things go wrong, and it is so important that concerns are dealt with appropriately.
• Suppliers of Electronic Patient Record (EPR) systems must ensure there is a standardised national maternity handover tool that addresses interoperability gaps between Trust systems. This tool must enable the consistent, real-time sharing of critical clinical information across organisational boundaries, particularly where women’s care is being accessed outside of their maternity booking Trust. As indicated above, it is often the downfall of many systems when the relevant medical history is not available to the person speaking with the patient.
• DHSC/NHSE must support Trusts to ensure that maternity services provide timely, accessible psychological support for women and families following traumatic events. This must include clear referral pathways, adequately resourced specialist provision, and processes that proactively identify and respond to unmet emotional and psychological needs. Improvement must be demonstrated through increased and equitable uptake of support services, high‑quality family-feedback data confirming that families feel supported and safe, and evidence that psychological care is embedded as a core component of the maternity safety response. It is crucial for women and families to have timely and appropriate access to mental healthcare, especially when there have been complications.
• All Trusts must ensure protected time for multidisciplinary governance, review and learning. This must include learning from both adverse events and examples of good practice to support continuous improvement in the quality and safety of care provided to women. Learning from neonatal PSIRF investigations should be considered alongside maternity investigations, recognising the opportunities for shared learning across perinatal services. Shared learning is what clinical negligence Solicitors regularly highlight to Defence organisations. An error within one Trust could be shared within the NHS system as a whole to prevent it from occurring elsewhere. It is noted that this recommendation only relates to shared learning within Trusts, but this is a very good start and can hopefully be expanded.
• Every Trust must appoint a maternity subject-matter specialist with a nationally standardised role description to address inconsistent expertise and oversight, ensuring women receive safer, more consistent governance. The maternity subject-matter specialist will represent the views of the multidisciplinary maternity team (midwifery, obstetric, anaesthetic and neonatal) at trust board level. Improvement measured through compliance with Ockenden IEAs and other national review actions. This will hopefully ensure that the IEAs are implemented within every Trust, but a national system of oversight is also something that is warranted.

Has It Made a Difference?

There have been pockets of progress. Some trusts strengthened staffing and training following earlier Ockenden recommendations. National awareness of listening to women, data collection and speaking‑up has increased.

However, the recurrence of similar themes across more than a decade remains striking. Failures to listen and escalate, problems with teamworking, inadequate staffing and defensive responses continue to appear across reports. Reports of a toxic culture, including instances of racism toward mothers, underscore the need for genuine cultural change alongside clinical improvements.

The NHS faces genuine and significant pressures. Workforce shortages, increasing clinical complexity, post‑pandemic demand and financial constraints make consistent delivery of high‑quality care more difficult. These realities provide context but do not remove the duty to provide safe and reasonable care.

From our perspective at Bond Turner, these inquiries provide powerful, independent evidence in clinical negligence claims. They help to establish what good care should have looked like and support fair compensation for lifelong needs. Litigation is a necessary route to justice for many families, but it should not be the mechanism on which safety depends.

A Constructive Way Forward

The pattern is now well established. Scrutiny produces recommendations. Some are implemented locally. National momentum then fragments under operational pressure.

A more effective response requires sustained investment in staffing, clearer accountability for implementation, and transparency in outcomes. There is also a need for more consistent, publicly available data to identify patterns of harm earlier, particularly where inequalities or systemic risks emerge across services. As a firm committed to women’s health clinical negligence, we support calls for robust sex-based data analysis to better understand and address differences in outcomes.

Independent oversight, robust investigation processes and meaningful engagement with families are critical. The system has become increasingly effective at identifying what has gone wrong. The challenge now lies in ensuring that learning is embedded in day-to-day practice and sustained over time.

Supporting Families Through Life‑Altering Harm

If your family has been affected by concerns around maternity or neonatal care, whether recently or in the past, specialist advice can help to clarify what has happened and what options are available.

At Bond Turner, we approach these cases with a clear focus. We listen carefully to families and their experiences. We obtain and analyse medical evidence in detail. We work with leading independent experts to establish whether care fell below a reasonable standard and, if so, whether that caused the harm.

Where appropriate, we pursue claims to secure compensation that reflects the full extent of a family’s needs. In cases involving serious injury, this often includes long-term care, therapy, equipment, accommodation and financial support for the future.

These cases require both legal expertise and a detailed understanding of obstetric and neonatal care. They also require persistence. Investigations can be complex and lengthy, particularly where records are incomplete or where initial explanations do not reflect the full picture.

Alongside individual cases, the legal process can play a wider role. Clinical negligence claims often bring together independent expert evidence, disclosure of records and detailed analysis of what happened. In doing so, they can contribute to a clearer understanding of failings and support wider learning across the system.

A Final Reflection

Over more than a decade, there has been no shortage of scrutiny, recommendations or ambition.

The consistent challenge has been translating that learning into practice, at pace and across the system as a whole.

The publication of the Nottingham report is another significant moment. The question now is not what the system knows, but what it will do with that knowledge.

For families who have come forward, often at great personal cost, that question matters deeply.