Ockenden Report Published: Key Findings on Nottingham Maternity Services

The Ockenden Report into Maternity Services at Nottingham University Hospitals NHS Trust

The Ockenden Report reviewing maternity services at Nottingham University Hospitals NHS Trust has been published today.

You can access the report here:

Findings, conclusions and essential actions from the independent review of maternity services at Nottingham University Hospitals NHS Trust

Donna Ockenden, a senior midwife, at the head of the investigation, and her team, spoke with women and their families about their experiences of maternity services at Nottingham, and maternity staff.

The investigation identified a number of themes running through the care at Nottingham:

1. Autonomy Information and Choice

“…Women frequently reported that they were not given meaningful choice or enabled to make informed decisions, that their preferences were dismissed, or that interventions were carried out without appropriate consent.

Many accounts describe situations where women felt coerced into changes to their care pathway, such as transfers, induction, or specific interventions, often framed as non-negotiable due to ‘policy’, ‘staffing’, or ‘protocol’, rather than medical necessity….

… Across diverse experiences the accounts consistently describe a culture of control and paternalism in maternity care. Women reported interventions being performed without adequate explanation, an absence of genuine shared decision-making, and situations where options were presented as instructions.

The recurring nature of such accounts at NUH suggests a systemic issue, not isolated events. The frequency and consistency of autonomy-related concerns across 2011–2024 indicate long-standing cultural patterns within NUH, echoing national concerns about paternalistic care and the failure of maternity systems to deliver truly woman-centred care.”

2. Staffing and System Constraints

The report indicates that understaffing was “one of the most pervasive themes”.

“…Women repeatedly described environments where midwives and doctors were overstretched, exhausted, and unable to respond promptly to requests for help…

…Women’s experiences reflect a maternity service operating under chronic resource pressure. The accounts describe:

• long waits for essential medication,
• delays in responding to emergencies,
• missed observations,
• inability to provide basic care,
• overwhelmed staff expressing distress…”

The report says that the findings of the Royal College of Midwives and the Care Quality Commission (CQC) regarding severe workforce shortages as “a major driver of maternity safety concerns in England” are mirrored in Nottingham and that there were “systemic pressures [that] persisted for more than a decade”.

It goes on to say:

“The experiences at NUH mirror these findings, suggesting systemic pressures persisted for more than a decade. The accounts demonstrate that staffing issues were not episodic but chronic and entrenched, impacting every stage of maternity care. This has deep implications for safety, emotional wellbeing, and confidence in the service.”

3. Continuity and Handover

The report confirms that many women experienced “disrupted continuity of care… with women seeing numerous midwives antenatally, intrapartum, and postnatally. Poor handover between midwives, shifts, and hospitals contributed to confusion, inconsistency, and feelings of insecurity.”

The investigation found that the lack of continuity at Nottingham was systemic over many years and may have been amplified by chronic staff shortages. It highlights that “…Continuity of care is internationally recognised as a protective factor for both safety and emotional wellbeing…”  and that a lack of continuity undermines the clinician/patient relationship of trust, increases the risk of potential medical mistakes and can contribute to “avoidable emotional distress”.

4. Emotional Safety and Trauma

The report states: “A substantial proportion of narratives described experiences of fear, abandonment, and trauma, including long-term psychological impact.”

Women shared with the investigation their traumatic experiences:

“25 years on I still feel traumatised…I felt suicidal.” (1996)

“I have PTSD five years later.” (2018)

“I was left alone and terrified. It felt totally traumatising.” (2022)

The report acknowledges that the emotional impact on women can be “significant and enduring”, with a direct impact on their lives. It emphasises that maternity-related trauma is not the result of clinical events alone, but also how women are treated by midwives and other clinical staff when complications and clinical events arise.

5. Intrapartum Care and Pain Relief

Women who shared their experiences during the investigation reported that they experienced “profound neglect”. This included:

• Lack of hydration
• Unclean wards
• Inadequate or no assistance with mobility after surgery
• Delayed assistance with feeding

6. Communication, Professionalism and Compassion

Sadly, many women reported that staff spoke to them unkindly, disrespectfully and dismissively. This type of behaviour is a consistent feature associated with “preventable harm in maternity services” and as reported in investigations into services at other NHS Trusts, an inherent feature of a culture of ‘unprofessional behaviour and callousness’.

7. Breastfeeding Support and Baby Feeding

The report confirms that women at Nottingham reported “inconsistent, coercive, or rough handling during breastfeeding support”.

It states that staff shortages impact the quality of feeding support offered to new mothers and their babies.

8. Safety, Basic Care and Observations

The report references a range of safety and basic care concerns including:

• Missed observations
• Delayed test results
• Unclean clinical environments
• Lack of basic care

It highlights that these failures indicate that there were “systemic governance weaknesses” at Nottingham.

9. Value of Individual Staff Members

Although clearly there were many negative experiences and concerning events documented through the investigation, the report confirms that there was also positive feedback from women regarding individual doctors, midwives and neonatal teams.

The report also raises concerns regarding ‘Leadership, Governance and Culture’ at the Trust.

“Multiple accounts describe fear of speaking up, dismissive attitudes becoming normalised, defensive behaviour from staff, families feeling ‘gaslit’ or blamed and staff expressing distress at their working conditions. All major inquiries conclude that leadership failings and dysfunctional organisational cultures are key drivers of unsafe maternity care.”

It particularly states:

“The NUH dataset suggests a weak safety culture, inadequate oversight, normalisation of deviance and inconsistent accountability mechanisms. These conditions allow unsafe practices to persist over time.”

The report acknowledges the very significant harm to women as a result of psychological trauma.

It is also highlighted that there were issues of “cultural misunderstanding”.

“Women from Black, Asian, and other global majority backgrounds, and those with diverse sexual orientations, reported experiences of stereotyping, assumptions, and lack of awareness of their cultural or social circumstances.”  

The inquiry ultimately concluded that the extent of the mistakes made by clinical staff, the chronic understaffing, lack of essential equipment and poor leadership contributed to “hundreds of mothers and babies [suffering] potentially avoidable harm or [death] due to deeply embedded “systemic failures””. The inquiry report also confirms that once concerns were first raised, the Trust did too little, too late.

The Report’s Conclusion

The report concludes by setting out clearly what the Trust must do to raise and maintain better standards of maternity care now and in the future. However, many are concerned that given the number of inquiries into antenatal and maternity services across the country to date, and with two further enquiries in Leeds and Sussex pending, not enough is being done on a national scale. The BBC reports that “Regulators like the General Medical Council and the Nursing and Midwifery Council have never been held accountable for failing to step in and protect patients when families have reported egregious conduct to them.”

Some families continue to call for a public inquiry into maternity care in England. Given the number of avoidable deaths and unnecessary harm revealed by the Nottingham and other inquiries, action needs to be taken to ensure proactive change and improvements are implemented across the country at all levels. Without this, it is difficult to see how adequate change will be achieved. As put by the BBC: “Until it embarks on a sustained and meaningful cultural shift, working cooperatively with patients and families, many fear it will continue to fail mothers and babies.”

Affected By Care At Nottingham or Other Trusts?

We represent individuals affected by maternity care at Nottingham and other Trusts across England.

If you or a loved one believe you may have suffered harm as a result of substandard maternity care, our specialist legal team can advise you on your options and whether you may be entitled to compensation.

Call us to discuss making a claim on a no win, no fee basis, email us at ab@phoenixlegalsolicitors.co.uk, or submit one of our contact forms to receive a free callback.

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