An independent review has concluded that maternity services at one of England's largest hospital trusts failed families over many years through systemic, repeated and avoidable errors — findings that have intensified scrutiny of safety in NHS maternity care nationally.
The review
The report, the final findings of the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust (NUH), was published on June 24 and led by senior midwife Donna Ockenden, the UK government confirmed. It examined the cases of more than 2,500 families — including stillbirths, neonatal deaths, brain injuries to babies, and severe maternal harm and deaths — making it the largest review of a single NHS service in the country's history. More than 160 clinical reviewers took part, and the team met over 500 families directly.
Ockenden previously led the landmark 2022 review into maternity failures at the Shrewsbury and Telford trust; the Nottingham investigation is larger still.
What it found
The review identified potentially avoidable outcomes in 444 maternity cases examined up to May 2025, alongside 76 neonatal cases, according to a summary by the Patient Safety Learning Hub. Some press accounts, including ITV News Central, reported that more than 500 mothers and babies died or were seriously harmed across the cases reviewed.
The report described repeated failures in listening to families, communication, escalating concerns and learning from mistakes. Reviewers found what they called a "normalisation of deviance" — a culture in which poor practice went unchallenged — and concluded the service "failed the people it existed to serve." Families, including women of color and younger mothers, reported having their concerns dismissed.
Legal and official fallout
The findings follow earlier accountability steps. In 2025, the trust pleaded guilty to charges of failing to provide safe care in cases involving mothers and babies and was fined a record sum for maternity failings, and police opened a corporate manslaughter investigation into the trust's services.
The government acknowledged the report's findings as deeply serious and apologized to affected families, pledging action to improve maternity safety across the NHS, including stronger mechanisms for patients and families to escalate concerns when they feel they are not being heard. The trust issued an unreserved apology, saying it accepted responsibility for its failings.
Calls for more
Campaigners and bereaved families welcomed the review but argued it did not go far enough, renewing calls for a full statutory public inquiry with legal powers to compel former senior managers to give evidence — something the independent review could not do.
Ockenden has been asked to lead further maternity reviews at other NHS trusts, a sign that the problems identified at Nottingham are not believed to be confined to one hospital. She framed the stakes plainly, noting that families come to maternity care with modest expectations — competence, honesty, safety, dignity and kindness — and that meeting them should not be a high bar.
