What is the Ockenden review?

The publication of Midwife, Donna Ockenden’s review into maternity services at Nottingham University Hospitals NHS Trust has been long awaited. It was commissioned in 2022 after families raised concerns regarding the safety of maternity care at the Trust. The review was finally published after a long and thorough investigation on 24^th June 2026. It was described as a report she and her team did not want to have to write and one the families of Nottingham should never have needed.

Over 2500 cases spanning a period of 13 years from 1 April 2012 to 31^st May 2025 were reviewed although concerns going as far back as 2007 were noted. 800 members of staff also provided input into the review. The cases reviewed involved mothers and babies who died or suffered serious and significant injuries, as well as cases where babies were stillborn.

The review is the largest maternity inquiry in the NHS’s history.

What did the review conclude?

The report is not evidence of a single incident. It is evidence of failings within a Trust on a very large scale. It highlights systemic failings against a background of bullying and racism by senior leaders, an environment described as “toxic”. Staff were afraid to speak up for fear of repercussions against them. The families when they did speak up encountered defensiveness and a lack of accountability. The Trust’s own internal investigations failed to highlight and address the issues.

The report concluded that:

• Mothers and babies suffered harm that may have been avoided because of longstanding failures at the Trust.
• There was a failure to prevent deaths by senior leaders despite them knowing there were serious issues in the maternity department.
• 444 maternity cases as well as 76 neonatal cases could potentially have been avoided.

The report grades cases where harm could have been potentially avoided at 2 or 3 dependent on whether different care would reasonably be expected to have altered the outcome (grade 3) or might have made a difference to the outcome (grade 2).

What happens following the review?

The report makes a very difficult read. It is clear in that things must change.

Within it, it sets out Local Actions for Learning, or LAFLs and Nationwide Immediate and Essential Actions, or IEAs to improve maternity care generally. 18 IEAs have been set out under 8 key headings.

The key headings are:

• Listening to women and families
• Workforce planning and safe staffing
• Training and multi-professional learning
• Risk Assessment throughout pregnancy
• Incident investigation and family involvement
• Governance and Board accountability
• Culture, teamwork and psychological safety
• Mothers who have died and post death care.

The 18 IEAs are:

• Strengthening women centered communication and informed choice
• Support a nationally agreed perinatal workforce planning methodology as a critical enabler of perinatal improvement at pace and scale
• National IEA for Labour Ward Co-Ordinator role
• All Trusts must support training for midwives in the use of speculum examination
• Enhanced maternal care
• Delivering safe, personalised and equitable maternity care through early risk recognition, coordinated care and responsive services
• National standard for standardisation and recording of fetal growth risk assessment
• There must be a national standard and documentation for maternity triage and record keeping in maternity care provision
• Support the development and implementation of a structured assessment framework for the latent phase of labour, ensuring clarity when the ‘latent phase of labour’ becomes abnormal and requires escalation
• All trusts must define criteria for the safe use of telephone postnatal follow up indicating when telephone follow up is acceptable or when face to face follow up is mandatory
• National standard for obstetric anesthetic record keeping
• Safe, accessible and comprehensive maternity anesthetic documentation
• DHSC/NHSE should introduce and support access to coordinated multi-disciplinary debrief and psychological support
• Funding for implementation of Maternity Patient Safety Incident Reporting Framework (PSIRF)
• Strengthened multidisciplinary governance and learning
• Foster a compassionate, psychologically safe and learning culture
• DHSC/NHSE should recommend and support recruitment processes and implement a consistent onboarding package for new starters
• All Trusts to ensure compliance, audited annually, with the NHS Management Code of Practice (2023)

In addition, the families are pushing the government for a statutory public inquiry, the Police are carrying out a separate investigation into the Trust and Regulators are considering various medical professionals’ “fitness to practice” certificates.

The Trust has issued a formal apology for the failings identified.

How can Hopkins help?

Our team of expert clinical negligence solicitors have many years’ of experience handling maternity claims on behalf of mothers and their babies. We would encourage anyone who has suffered an injury in childbirth at Nottingham University Hospitals NHS Trust, any other Hospital Trust, or has been affected in general by the outcome of the Ockenden review to contact us for a no obligation discussion about whether you may have grounds for a claim.

To contact our team, please click the Request a Callback button below, or give us a call on 01623 468 468.