The Donna Ockenden Independent Maternity Review was published yesterday after nearly four years of investigation into Nottingham University Hospitals (NUH) NHS Trust’s maternity services.
The publication of the final review marks a significant moment for families affected by maternity care failings at Nottingham University Hospitals Trust. The review follows years of concerns about patient safety, investigations and accountability within the Trust. These findings come against the backdrop of ongoing scrutiny of NUH’s services, including concerns highlighted by the Care Quality Commission in our previous article examining why Nottingham University Hospitals Trust still requires improvement.
More than 2,500 families came forward who met the scope of the review’s terms of reference, alongside current and former members of staff. Donna Ockenden’s review team considered every family’s case to assess the standard of care received, the severity of the concerns raised, and whether different care might reasonably have altered the outcome.
Donna gave thanks to the core families to whom the review owes its existence. Sadie Simpson, Associate Clinical Negligence Solicitor and Inquest Specialist at Ison Harrison, continues to represent two of the core families involved in the review.
It was the determination of these families to pursue answers, truth and accountability that led to the review being established. Whilst accountability is still being sought, Donna Ockenden’s address today represents a significant step forward and a hopeful turning point for the lasting and essential changes needed within maternity services. It acknowledged that families’ concerns had been heard and that lessons must be learned to improve care in the future.
What Did the Donna Ockenden Review Find?
One of the most concerning findings of the review was that major concerns were not being properly investigated year after year within the Trust. These failings continued for more than a decade, which reflects the lived experience of many families who have suffered harm in similar circumstances.
The devastating impact of these failures on mothers, babies, fathers and wider families cannot be overstated. For many, the consequences are lifelong and irreparable.
The findings were not isolated incidents but reflected a pattern of systemic failures within Nottingham University Hospitals NHS Trust. The review identified repeated concerns around patient safety, communication, incident reporting and organisational learning. For many families affected by maternity negligence, birth injury or avoidable harm, the report provides long-awaited recognition of concerns that had previously gone unanswered.
A key finding was that mothers’ concerns were not listened to, escalated or acted upon, leading to avoidable harm in numerous cases.
The review also identified a recurring failure to properly investigate serious incidents, allowing preventable harm to happen to other families. This highlighted a lack of collective accountability within the Trust. The review found that the Trust often failed to learn from incidents and avoided carrying out reviews of care using its own internal grading system. In more than 100 cases, significant concerns regarding patient care were never classified as serious incidents.
Donna Ockenden’s review includes local actions for learning specifically for Nottingham University Hospitals NHS Trust, alongside eight Immediate and Essential Actions intended to drive improvements across maternity services nationally.
Donna Ockenden made clear that these actions “were not aspirational and are essential and must be implemented.”
What Happens Next for Nottingham University Hospitals?
The review itself is not statutory, meaning the government cannot compel the Trust to implement its recommendations. However, the Trust, MPs and the Health Secretary have publicly expressed concern regarding maternity services and have emphasised the need for meaningful change.
As Donna Ockenden stated, “the time for talking and reflection is over.”
The challenge now will be ensuring that commitments translate into genuine and measurable improvements for families using maternity services.
Alongside the review, a National Rapid Maternity Review is currently underway and is expected to be published in due course. In May 2026, Michelle Welsh MP was appointed as the Government’s first Maternity Adviser and will work directly with families to help shape future policy and drive improvements in maternity care.
Support for Families Affected by Maternity Care Failures
For many families, the publication of the review may raise difficult questions about the care they or their loved ones received.
Whilst the review itself does not determine legal liability or entitlement to compensation, it may encourage some families to seek answers regarding events surrounding a pregnancy, birth injury, stillbirth, neonatal death or maternal injury.
Seeking legal advice is not solely about pursuing a claim. Many families simply wish to understand what happened, whether the care they received met acceptable standards, and whether opportunities existed to prevent the outcome they experienced.
At Ison Harrison, our Clinical Negligence team has extensive experience supporting families affected by maternity care failures, birth injuries and avoidable harm. We understand the sensitivity of these cases and provide compassionate, confidential advice tailored to each family’s circumstances.
If you have concerns about maternity care received at Nottingham University Hospitals NHS Trust or another NHS provider, our team can discuss your situation and explain the options available to you.
A Turning Point for Maternity Care?
Sadie Simpson, a solicitor at Ison Harrison who is representing some of the families, commented:
“Donna’s address was very powerful and emotional, having worked with a number of families who have suffered harm at Nottingham. It unfortunately brings to light many failings that have been apparent for over a decade.
I am hopeful that her findings will be implemented and that this will stand as a crucial turning point for safe, equitable maternity care, which all mothers and babies deserve as a basic minimum across England.
It is devastating for the many families whose loved ones and babies should be here today had reasonable, and in some cases basic, care been provided. I am very privileged to represent families who have shown such courage and strength in their pursuit of answers.
However, it is now time for the government and the Trust to play their part and make lasting improvements.”
Although yesterday’s publication marks the end of the review, for the families involved their lives remain forever changed. Their fight for accountability continues with the police investigation Operation Perth ongoing and the further fight for the regulators to be held responsible for failing to act. Today represents an important acknowledgement of the experiences they have shared and the concerns they have raised over many years.
