Understanding the Nottingham findings and what they mean for affected families
The Ockenden Maternity Review has become one of the most significant investigations into NHS maternity care in living memory.
It began with serious failings at Shrewsbury and Telford Hospital NHS Trust, where as many as 200 babies may have died as a result of repeated failures. In 2026, the review returned to national attention following the publication of Donna Ockenden’s final report into maternity services at Nottingham University Hospitals NHS Trust.
Recent BBC coverage of the Nottingham findings has set out the scale of the harm in stark terms. The review found hundreds of potentially avoidable outcomes for mothers and babies, including babies who died or were left seriously injured due to substandard care. It also highlighted a workplace culture described as bullying and toxic, failures to listen to women and families, missed opportunities to escalate risk, and serious problems with post-death care.
For families reading those findings, the issue is not abstract. Behind every statistic is a mother, baby and family who trusted maternity services at the most vulnerable point in their lives.
In this piece we explain what the Ockenden Maternity Review found, why the Nottingham findings matter in 2026, and what support may look like for families who believe their own care fell short. This is a plain-English explainer, not legal advice, and every family’s situation is different.
Nimish Patel, Head of Clinical Negligence at McHale & Co Solicitors said:
“The Ockenden review highlights the fundamental underlying issues within the maternity services which affect the ability to provide safe and effective care for mothers and their babies when they are at their most vulnerable in hospitals across the country. The spotlight of staff shortages, facilities and training issues are often raised within claims which I have run over the past 15 years but the same response seems to come from hospitals in that they will learn from their mistakes and reflect. The time has now come for action and real change which will hopefully be brought about by the appointment of the Maternity Commissioner.”
The Nottingham report, and the BBC coverage that has followed, reinforce the point that maternity safety cannot be treated as a historic issue or a problem isolated to one hospital trust. The same themes appear repeatedly: staffing pressures, missed warning signs, poor communication, weak escalation, defensive leadership and families feeling that their concerns were dismissed.
What is most troubling about these findings is how familiar the themes are. Families raise concerns, warning signs are missed, hospitals say lessons will be learned, and yet the same failures appear again in another trust, another review and another set of devastated families.
Key Takeaways
What it is: The Ockenden Maternity Review (officially the Ockenden Review) is a series of independent investigations into NHS maternity and neonatal care, starting at Shrewsbury and Telford and later extending to Nottingham University Hospitals NHS Trust.
Scale of the Shrewsbury and Telford investigation: 1,486 families were involved, resulting in 60 local actions for learning.
Scale of the Nottingham investigation: around 2,500 family cases were reviewed. BBC reporting on the final report said different care may have altered the outcome for 260 babies who died or were harmed, including 155 babies who died and 105 who suffered serious injury due to substandard care.
Repeated themes: capacity pressures, poor leadership culture, racism and discrimination, weak accountability, and workforce shortages appear across every chapter of the Ockenden Maternity Review.
National picture: 36% of maternity services in England were rated as requiring improvement following CQC inspection.
Ongoing impact: the findings continue to shape NHS maternity care investigations and safety reforms into 2026.
Getting support: families who have questions about their own care can explore next steps through what action can be taken after a maternity care failure.
What Is the Ockenden Maternity Review?
The Ockenden Maternity Review is named after Donna Ockenden, the senior midwife who was asked to lead an independent investigation into maternity services at Shrewsbury and Telford Hospital NHS Trust back in 2017.
What started as a single-trust investigation at Shrewsbury and Telford became part of a much wider national conversation about maternity safety. Donna Ockenden was later appointed to lead a separate independent review into maternity services at Nottingham University Hospitals NHS Trust, shining a light on failures that were far from isolated.
The History Behind the Ockenden Maternity Review
The first phase focused on Shrewsbury and Telford. Over a five-year investigation, 1,486 families came forward with concerns about the care they’d received.
According to the Safer Healthcare and Biosafety Network, that investigation concluded that as many as 200 babies may have died due to repeated failures at the trust. It’s a stark figure, and it’s the one that first pushed maternity safety into the national conversation.
The second, larger phase turned its attention to Nottingham University Hospitals NHS Trust. This chapter of the Ockenden Maternity Review examined around 2,500 family cases, making it the largest maternity investigation of its kind in NHS history.
The final Nottingham report, published in June 2026, found potentially avoidable outcomes for mothers and babies in hundreds of maternity and neonatal cases. According to BBC reporting on the review, different care may have altered the outcome for 260 babies who died or were harmed. Of those, 155 babies died and 105 suffered serious injury due to substandard care.
The review did not point to one single cause. Instead, it identified a pattern of linked failures, including poor monitoring of babies, incorrect interpretation of heart monitoring, failure to recognise distress during labour, and failure to escalate concerns to senior doctors quickly enough.
It also found that many of the problems had been known about for years. Donna Ockenden said serious issues at the trust went back to “at least 2010”, raising difficult questions about why more was not done sooner to prevent further harm.
The findings show why early concern must be treated seriously. In maternity care, delay can change everything. If a mother says something feels wrong, or if monitoring suggests a baby may be in distress, the response has to be immediate, careful and properly escalated.
What the Ockenden Maternity Review Found: Key Statistics
The detail in the Nottingham findings is uncomfortable reading, but it’s important context for anyone trying to understand what actually went wrong.
Maternal deaths with significant or major concerns where different care might have saved the mother: 21.4%
Unexpected ITU admissions classed as preventable through better management: 35.6%
Neonatal deaths classed as preventable (Grade 2 or 3): 12%
Cases originating from families in the most deprived areas of England: 35%
Maternity services in England rated as “requires improvement” by the CQC: 36%
According to EMJ Reviews, more than half of the cases involving a baby with hypoxic brain injury were classed at a grade where better care could reasonably have changed the outcome.
Source: EMJ Reviews
The independent review examined decades of maternity care failures, hearing from thousands of affected families.
The 15 Immediate and Essential Actions
Alongside the statistics, the Ockenden Maternity Review set out 15 areas identified for immediate and essential action across all maternity services in England, not just the two trusts under direct investigation.
These cover things like safer staffing levels, more consistent risk assessments during labour, better multidisciplinary training, and clearer escalation processes when something starts to go wrong. It’s a long list, and putting it into practice across an entire national health service was never going to happen overnight.
The reality is that reform on this scale takes years, and families are still living with the consequences of care that happened long before any of these actions were agreed.
These actions came from the earlier Shrewsbury and Telford phase of the Ockenden Review, but they remain relevant because the Nottingham findings show many of the same underlying issues appearing again.
Capacity, Culture and Accountability: The Common Threads
Read enough of the Ockenden findings and the same themes keep resurfacing: too few staff, missed warning signs, poor leadership, unsafe culture, and families who were not listened to when they raised concerns.
The Nottingham report gives those themes renewed urgency.
BBC coverage of the report described a workplace culture that had been allowed to become bullying and toxic over several years. Staff reported that poor behaviour had become normalised, while families described being dismissed, minimised or made to feel like their concerns were an inconvenience rather than a warning sign.
The clinical themes are just as serious. The review identified repeated issues with monitoring babies, interpreting heart monitoring, recognising distress during labour, and escalating cases to senior doctors. These are not minor administrative failings. They are the points at which safe maternity care can break down.
The review also raised concerns about unequal treatment. Women whose first language was not English did not always receive adequate communication support, and staff described racist attitudes towards Black women who were labelled as too loud or too demanding.
A safe maternity service depends on people being able to speak up. That includes mothers, families, midwives, doctors and support staff. When a culture develops where concerns are dismissed or people feel unable to challenge decisions, patient safety is inevitably put at risk.
The Nottingham findings also underline why accountability matters. Families should not have to fight for years to prove that their concerns were justified. Where care has fallen below an acceptable standard, there must be proper investigation, clear answers and meaningful change.
Who Was Affected: Families at the Heart of the Ockenden Maternity Review
It’s easy to talk about the Ockenden Maternity Review in terms of statistics and inquiry names. Behind every figure, though, is a family who trusted the NHS with the safe arrival of their child.
Analysis by 1 Crown Office Row found that 35% of the Nottingham cases came from families living in the most deprived areas of England, a pattern that raises uncomfortable questions about whether care was equally safe for everyone.
These aren’t abstract numbers. They represent thousands of parents who are still asking, years on in some cases, exactly what happened to them and why.
Families Should Not Have to Fight to Be Heard
One of the most powerful parts of the recent BBC coverage is the role played by bereaved families themselves.
The BBC reported how Gary and Sarah Andrews contacted Sarah and Jack Hawkins after recognising similarities between the death of their daughter Wynter and the death of Harriet Hawkins. Their connection became part of a wider campaign that helped bring more families together and contributed to the independent review being established.
That matters because it shows how isolated families can feel after a maternity failure. Too often, parents are told that what happened was a tragic one-off, a known complication or something that could not have been avoided. In Nottingham, families finding one another helped reveal that the same kinds of concerns had been raised before.
Nimish Patel said:
“No family should have to become an investigator to be believed. When parents are forced to search for other families with similar experiences before their own concerns are taken seriously such as the Maternity Safety Alliance, something has gone badly wrong with the system. When I attended one of their meetings, I noticed that similar groups have been formed in other parts of the country in response to issues raised by other Trusts..”
For families affected by maternity failings, being heard is often the first step. Many want to understand what happened, whether different care could have changed the outcome, and whether the same thing could happen to another family. A legal claim is not only about compensation. In many cases, it is also about disclosure, accountability and answers.
Our Clinical Negligence Team
We work with families every day who are trying to make sense of what happened during their maternity care. Our clinical negligence team includes solicitors who focus specifically on birth injury, antenatal, and neonatal claims.
Our team has experience reviewing medical records, gathering evidence, and supporting families through a process that can feel overwhelming from the outside.
Support for Families Affected by Maternity Care Failures
If any of the themes in the Ockenden Maternity Review sound familiar, whether that is concerns being dismissed, delayed escalation, poor monitoring, a lack of informed consent, or unexplained harm during labour or neonatal care, it may be worth seeking specialist advice.
Families often come to us with difficult questions:
Could this have been avoided?
Were warning signs missed?
Should concerns have been escalated sooner?
Were we properly informed about risks and options?
Did poor communication affect the care received?
Why does the hospital’s explanation not match what we remember happening?
These are not easy questions to answer without reviewing the medical records and the circumstances in detail. Every case is different, and not every poor outcome means there has been clinical negligence. However, where care fell below an acceptable standard and caused avoidable harm, families may be able to bring a claim.
Our clinical negligence team supports families with birth injury, antenatal, neonatal and maternity care claims. We can help review what happened, obtain relevant records, consider expert evidence and explain the options available.
Conclusion
The Ockenden Maternity Review has forced a national reckoning with maternity safety, first through Shrewsbury and Telford and now through Nottingham.
The latest Nottingham findings show that the issue is not simply one of individual mistakes. The review points to deeper problems: unsafe cultures, poor escalation, missed warning signs, inadequate leadership, and families who were not listened to when they raised concerns.
Donna Ockenden has said that maternity services at Nottingham are “not where it was, but it is not yet where it needs to be.” For families affected by maternity failings, that distinction matters. Progress may be happening, but it does not undo the harm already suffered or answer the questions many families still have.
Nimish Patel said:
“The hope is that the appointment of a Maternity Commissioner and the publication of these findings will lead to real change. But for the families affected, the priority remains much more immediate: answers, accountability and the reassurance that lessons are not simply promised, but acted upon.”
If you have concerns about maternity care you or your family received, the right next step is a direct, individual conversation with a specialist. A general article can explain the background, but proper advice depends on the facts of your own case.
Frequently Asked Questions
Why is the Ockenden Maternity Review back in the news?
The review returned to national attention in June 2026 following the publication of Donna Ockenden’s final report into maternity services at Nottingham University Hospitals NHS Trust. BBC coverage of the report highlighted hundreds of potentially avoidable outcomes for mothers and babies, serious cultural concerns, and the role of affected families in bringing the scandal to light.
What did the Nottingham maternity review find?
The Nottingham review found potentially avoidable outcomes in hundreds of maternity and neonatal cases. According to BBC reporting, different care may have altered the outcome for 260 babies who died or were harmed, including 155 babies who died and 105 who suffered serious injury due to substandard care.
What problems were identified in the Nottingham maternity report?
The report identified a number of serious issues, including poor monitoring of babies, failures in interpreting heart monitoring, failure to recognise distress during labour, delayed escalation to senior doctors, insufficient staffing, poor training, toxic workplace culture and families not being listened to when they raised concerns.
Why were families so important to the Nottingham review?
Families played a central role in bringing the scale of the Nottingham maternity failures to public attention. BBC reporting highlighted how bereaved families connected with one another after recognising similarities in their experiences, helping to show that the problems were not isolated incidents.
What should I do if I am worried about maternity care I or my family received?
If you are worried about maternity care, it may help to write down what happened, request copies of relevant medical records and speak to a solicitor who specialises in clinical negligence. A specialist can help you understand whether the care may have fallen below an acceptable standard and whether further investigation is appropriate.
