(Adnkronos) – Over 500 women and children have died or suffered potentially avoidable harm at Nottingham’s “toxic” university hospital trust due to “deep-rooted systemic failures.” This is revealed by what is considered the largest maternity inquiry in the history of the British National Health Service (NHS), which began in 2023 following complaints from parents collected by a midwife, Donna Ockenden. Shocking data in a 401-page report reveal how 444 mothers and 76 newborns suffered “avoidable” consequences in the last 13 years at the Nottingham University Hospitals NHS Trust. Managers, the report continues, were aware of serious problems in the maternity ward but did not intervene. What Nottingham hospital has done so far is pay millions of pounds in compensation and fines for complaints about poor quality of care.
The trust oversees two hospitals, Queen’s Medical Centre and Nottingham City Hospital, where the inquiry found “many” women received dangerously substandard and sometimes “cruel” care. Furthermore, it states, staff shortages were an established practice, nothing was learned from patient safety incidents, and a “toxic, bullying culture” prevailed.
Ockenden and her team of maternity experts, who conducted the three-year inquiry, examined the deaths of 27 mothers between 2006 and 2024 and “identified care deficiencies that may have had or had a substantial impact on the outcome in six deaths.” Furthermore, the Ockenden report states that “in several cases, failures contributed to severe neonatal injuries, stillbirths, and neonatal deaths.”
Among the widespread problems cited for newborn deaths are lack of oxygen, inadequate labor management, hospital-acquired infections, and poor postnatal care. Numerous cases are also cited demonstrating how deficiencies in neonatal care “may have contributed to long-term brain damage” and other neurodevelopmental outcomes in newborns. Leadership instability was a “determining factor,” with a “toxic and bullying corporate culture” persisting for years within the trust, the document continues. Staff reported to the inquiry team that there was a culture that “did not admit women in labor.” Furthermore, the trust’s managers were considered “invisible, unapproachable, and unresponsive.” The “toxic bullying culture” lasted for years and resulted in women receiving inadequate care, the inquiry states.
Delays in recognizing and managing postpartum hemorrhage, as well as severe obstetric hemorrhages, caused harm to women, who reported feeling unheard, inadequately informed, and unsupported. Furthermore, inadequate communication was not provided for women whose native language was not English. Some mothers with very high blood pressure or whose health conditions were worsening were not adequately assessed after childbirth, and “errors in the recognition and management of sick or feeding-difficult newborns” occurred, the report states. Some patients spoke of adequate analgesics, and one woman described childbirth as “a brutal, traumatic experience; they yelled at me, ‘you need to calm down’.” Approximately 2,500 families and 850 current or former employees provided testimonies to the review group, which examined events that occurred between 2012 and 2025.
James Murray, the British Health Minister, intervened in the case, stating that “Martha’s Rule,” which guarantees patients the right to an independent second opinion on their care from a separate clinical team, would be implemented in every maternity ward in England, as suggested by Ockenden. In the future, he added, current or former NHS staff who refuse to testify in maternity inquiries will also be compelled to do so, under penalty of up to two years imprisonment. Murray’s goal is to break the deeply ingrained “culture of silence” that often accompanies care deficiencies and medical negligence.
Murray promised that the government and NHS leadership “will make lasting changes” to improve maternity services across England. The findings of Ockenden’s inquiry will help define an action plan for reforming birth services that the Department of Health and Social Care’s maternity task force is developing, he added.
