More than 500 mothers and babies suffered potentially avoidable harm or died due to “deeply embedded systemic failures” at a “toxic” hospital trust, a review has found.
The inquiry, led by senior midwife Donna Ockenden, found leaders at Nottingham University Hospitals NHS Trust (NUH) knew there were serious issues in its maternity department going back years, but failed to take action to prevent more deaths. Overall, 520 mothers and babies suffered potentially avoidable harm or death, including 94 babies who were stillborn.
There were 62 neonatal deaths of babies overall. Assessors found babies died from a range of conditions, including from oxygen starvation, mismanaged labour, hospital-acquired infections and poor postnatal care delivered by midwives and doctors.
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Zahra KhaliqToday22:27 BST
Secondary victims of maternity trauma may be able to bring their own cases against trusts for psychiatric illness brought on by witnessing their partner or baby suffer injury or die, Health Secretary James Murray says.
“Fathers, partners and others are actively encouraged to be present to support mothers through labour and delivery, however the law does not allow them to bring their own claims for the psychiatric illness suffered as a direct result of witnessing their partner or baby suffer injury or die,” Murray said.
Health Secretary James Murray(Image: Ben Bauer/PA Wire)
Murray said he had asked barrister and former Labour MP David Lock KC to work with civil servants on the issue.
He will also be speaking to the chief executive of NUH, Anthony May, about the trust’s response to the Ockenden review.
Zahra KhaliqToday21:39 BST
A total of 550 people involved in the maternity review have been referred for psychological support.
The Family Psychological Support Service said it would continue to accept referrals and was able to provide services to “anyone in the family who’s been impacted by the Ockenden review,” operational directorJen Moon said.
Zahra KhaliqToday20:34 BST
Asked to elaborate on her comment that she would be “watching NUH really closely,” Donna Ockenden said she did not want a repeat of a situation in Shrewsbury when families told her there had been no engagement two years after a review of their maternity services.
“I didn’t think I would have to go back [to Shrewsbury], but I did,” she said. “Myself and a very small team on a part-time basis will help the [NUH] to set up a process of learning and improvement.
“It’s going to be an ongoing process and I will continue to spend some time in Nottingham over the next 18 months to two years.”
Donna Ockenden speaks to the media after presenting the findings of the report(Image: Joseph Raynor/ Reach PLC)
Bereaved parents Gary and Sarah Andrews say maternity services will not improve until there is full accountability. Sarah said:
Having spent so many years fighting and being ignored, it’s a relief knowing that you’ve been listened to. Everything that we’ve been saying for years is true. Maternity services will not improve until there is full accountability, and we need answers from the regulators.”
Gary added:
We met with a lot of the families and the key themes you hear in the report, we have lived experiences of that. It was striking to me 800 members of NUH staff were involved in the review – it shows they want positive change. But the lack of engagement from senior leaders – some still working in the NHS – is staggering.”
Gary and Sarah Andrews(Image: Joseph Raynor/ Reach PLC)
By Martin Bagot, Health and Science Editor
Many bereaved families are now demanding a full statutory public inquiry which can force witnesses to testify under oath and compel organisations to produce documents.
Senior physiotherapist Sarah Hawkins and her hospital consultant husband Jack lost their first child, Harriet, after failings in their care.
Sarah Hawkins and Jack Hawkins have demanded a full statutory public inquiry(Image: Joseph Raynor/ Reach PLC)
Directly addressing former NUH colleagues during the affected families’ press conference, Mr Hawkins said:
We recognise that some of you have been expected to work in a constant state of crisis within a culture where bullying, intimidation and the fear of speaking up … too often felt normal. The fact that a significant number of senior staff chose not to participate in this review is appalling. You have demonstrated that maternity safety doesn’t matter to you, that self-preservation does. It shouldn’t have taken us as harmed and bereaved families to campaign for years and years, a decade, to be able to get some answers. And now we need accountability. And that’s why we need the public inquiry.
Sarah added:
They need to be compelled to give evidence. Those clinicians, are they clinically safe if they don’t have patient safety at their heart?
Martin BagotToday18:49 BST
Emily Stringer, whose daughter Caitlin suffered a preventable brain injury when she was born in 2021, said her case was “not isolated” like the trust tried to make out. Ms Stringer said that due to her poor care, her daughter could not walk or talk and was partially sighted.
“It’s the validation that we never wanted but it’s amazing to have,” she said of the report. “Our family and 2,500 others in Nottingham have been heard – we are not the isolated case the trust tried to make us out to be.
“Many staff members have suffered real physiological harm – they need to be supported. The perpetrators of the toxic bullying culture need to be held to account,” Ms Stringer told the BBC.
Emily Stringer (right) speaks as maternity review families deliver a press conference(Image: Joseph Raynor/ Reach PLC)
By Martin Bagot, Health and Science Editor
Gill Walton, chief executive of the Royal College of Midwives, said the report highlights the staffing emergency that members have been warning about for years – not just in Nottingham, but across the country. She said:
Today is first and foremost about the families in Nottingham who were failed at one of the most important moments of their lives. Behind every finding in this report is a family whose lives have been changed forever. This report exposes more than a decade of leadership and institutional failure. At the heart of that failure was a healthcare system that refused to listen to women, to families and to the midwives who were raising the alarm for years. This report reflects the staffing emergency that our members have been warning about for years – not just in Nottingham, but in trusts across the country. Midwives raised the alarm and were not listened to. The consequences for families have been devastating. Women and babies cannot receive consistently safe, personalised and equitable care without safe staffing.
Martin BagotToday18:12 BST
Sarah Hawkins – whose daughter Harriet tragically died in the womb – said she was grateful for the group effort in fighting for the truth.
“There’s some sense of relief to be finally heard and believed, that was massive for me,” she said. “We’ve done this as a group effort, wouldn’t have done it without the rest of the families, we grew in number and grew in strength.
Dr Jack Hawkins and Sarah Hawkins(Image: Joseph Raynor/ Reach PLC)
“But it’s frustrating that families and victims have had to fight in this way. Why did the staff not do something 10 years ago?”
Her husband, Dr Jack Hawkins added: “We’ve been here before with reports into maternity scandals, why are we still here? Why are families still pushing for this?
“The weight of victim support is so huge. If it wasn’t for us families; I have zero faith things would change.”
Zahra KhaliqToday18:00 BST
By Martin Bagot, Health and Science Editor
Nick Carver, NUH trust chairman and Anthony May, chief executive, who both joined in 2022, apologised in an open letter and said while improvements have been made, there is more to do.
They said: “We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services.”
Chair Nick Carver and CEO Anthony May of NUH(Image: Joseph Raynor/ Reach PLC)
By Martin Bagot, Health and Science Editor
Clea Harmer, chief executive of baby loss charity Sands, said she welcomes the Government’s plans to strengthen both the voice of parents and the accountability of NHS staff, “by rolling out Martha’s Rule across all maternity and neonatal settings in England, and compelling NHS staff to give evidence to maternity reviews.”
She adds:
The serious and sustained maternity failures in Nottingham painfully highlighted how parents and families were not listened to, and how staff – particularly senior executives and board members – have until now been able to refuse to engage with maternity reviews. We also welcome the review of incidents and internal records in mortuaries, as acknowledging the importance of the existence of all those babies who die and pregnancies which are lost. It is essential that they are treated with dignity and respect after death.”
Martin BagotToday17:20 BST
By Martin Bagot, Health and Science Editor
At the same time as the report was published, the government has announced the rollout of ‘Martha’s Rule’ to all maternity units in England. Martha’s Rule gives families formalised, 24/7 access to a second opinion and is being advertised throughout hospitals.
The scheme was created after 13-year-old Martha Mills developed sepsis in 2021 and her parents’ pleas to have her treated for the infection went ignored. A coroner later ruled she would have survived if medics had transferred her to intensive care earlier.
Martha Mills died after developing sepsis in 2021(Image: PA)
Parents on all maternity wards will have a legal right to request a rapid review if a baby or mother’s condition is deteriorating and they are concerned staff are not responding to this.
The scheme has been rolled out for inpatients in every acute hospital in England and has been piloted in 15 maternity and neonatal settings
The Department for Health and Social Care said rollout to more is expected this year.
Martin BagotToday17:02 BST
By Martin Bagot, Health and Science Editor
Kate Brintworth, chief midwifery officer for NHS England, said the report shows “the scale of what still needs to change” as she pledged to introduce new national clinical standards to prevent harm.
“My thoughts are with those who have been harmed, bereaved or let down by the care they received,” she said. “They have shown extraordinary courage in speaking up, and their voices must be at the centre of how the NHS responds
Families pictured at the meeting today(Image: Joseph Raynor/ Reach PLC)
“We’ve introduced new national clinical standards which are helping prevent harm and ensure women get urgent maternity care more quickly, and local leaders and staff in Nottingham are working hard to address these failings. However, this report shows the scale of what still needs to change.”
Martin BagotToday16:37 BST
By Martin Bagot, Health and Science Editor
Reacting to the report, Health Secretary James Murray said: James Murray said: “I want to thank Donna for her vital and extensive work on this Independent Review, exposing serious systemic failures and a culture of silence that underpinned the harmful care so many families received.
“Her work has sought the truth for these families, who have waited in heartbreak for too long.
“Donna’s determination is matched by the courage of the families. I met them in Nottingham last week and heard first-hand about their devastating loss.
“We owe it to them to deliver lasting change. We will reflect on these findings and lessons from Nottingham will form part of our national plan to deliver real improvements in maternal and neonatal care for all families.”
Health Secretary James Murray(Image: Peter Byrne/PA Wire)
Canterbury MP Rosie Duffield, chairwoman of a parliamentary group on birth trauma, has described maternity care as a “postcode lottery”, saying inquries into failures at individual NHS trusts are failing to tackle the problem across the country.
“Are you lucky enough to live somewhere where it’s safer than somewhere else, which is awful?,” she said.
Ms Duffield has also echoed calls for a statutory public inquiry to stop the NHS “lurching from crisis to crisis”.
Rosie Duffield (file image)(Image: House of Commons/PA Wire)
By Martin Bagot, Health and Science Editor
The report blames “longstanding and deeply embedded systemic failures” at the hospital trust.
From at least 2012 there was a “running theme of poor governance within maternity”, including serious incidents not being investigated and a failure to learn and change after incidents.
Some managers were described as “invisible, unapproachable and unresponsive” who ignored concerns, bullied people, and were rude and aggressive.
CEO Anthony May of Nottingham University Hospitals (NUH) pictured as the findings are presented(Image: Joseph Raynor/ Reach PLC)
By Martin Bagot, Health and Science Editor
The report includes harrowing accounts where mothers told of inadequate pain relief, with one saying “It felt brutal… traumatic… they were screaming at me… ‘you need to pull yourself together’…”
Another patient said staff were dismissive and said “Is this your first baby…? Take some paracetamol and have a hot bath.”
Martin BagotToday15:46 BST
By Martin Bagot, Health and Science Editor
The report found “toxic bullying culture among labour ward co-ordinators” resulted in women receiving inadequate care.
Women in labour suffered delays in being examined and there were cases where staff were reluctant to escalate concerns and transfer to the labour ward.
There were delays in escalation of life threatening bleeds such as postpartum haemorrhage and major obstetric haemorrhage.
Donna Ockenden, Chair of the Ockenden Maternity Review, presents the findings of the report(Image: Joseph Raynor/ Reach PLC)
By Martin Bagot, Health and Science Editor
Overall the review outlined 520 mothers and babies suffered potentially avoidable harm or death, including 94 babies who were stillborn. It identified such potentially avoidable neonatal deaths in the case of a further 62 babies in the newborn period.
Cases were graded as 2 or 3 for harm, with grade 2 representing “significant concerns” and grade 3 “major concerns” over care.
Nottingham families are presented the findings of the independent report(Image: Joseph Raynor/ Reach PLC)
Grade 2 represents sub-optimal care where different management might have made a difference to the outcome, and grade 3 is where different management would reasonably be expected to have made a difference.
Overall, 31 reviews into baby neonatal deaths at the trust were found to include potentially avoidable harm at grades 2 and 3. At least eight of these babies should have survived.
Another 30 cases of potentially avoidable harm related to “massive obstetric haemorrhage”, and 12 reviews into babies were found to have significant or major concerns relating to brain damage due to a lack of oxygen.
Martin BagotToday14:50 BST
By Martin Bagot, Health and Science Editor
A theme familiar to NHS maternity scandals over the last two decades has resurfaced today – dangerously low staffing levels.
Staff described routinely working “beyond safe capacity” and the report days these “operational pressures” affected all areas of maternity care. The report links this to “a culture of not admitting women who were seeking admission in labour” and “discouraging women to attend in-person”.
One staff member said: “There was nowhere for those women to safely go to, because they were perceived as bed-blocking on labour suite”. Another said: “Honestly, when I worked there, it would be when [women] complained enough, when they complained loud enough.”
Martin BagotToday14:39 BST
By Martin Bagot, Health and Science Editor
Staff reported “a culture of organisational denial” over years, where poor outcomes “were regularly dismissed as `known complications’.”
Detailing the case of Jack and Sarah Hawkins, Donna Ockenden said baby “Harriet’s avoidable death was compounded by a systemic cover-up and investigations designed to mislead, which took a profound toll on the couple’s wellbeing”.
She added that the list of organisations that failed the Hawkins family include the trust, the Nursing and Midwifery Council, the Human Tissue Authority and the Care Quality Commission (CQC) regulator.
In her introduction to the report, Ms Ockenden said: “The culture of compounding of harm needs to stop”.
Martin BagotToday14:35 BST
James Murray also detailed the way in which the bodies of dead babies were wrongly handled by Nottingham University Hospitals NHS Trust.
Mr Murray’s voice faltered as he said failures at maternity services showed there was a “level of disrespect and lack of humanity that, I’ll be honest, left me aghast”.
He said babies were referred to as a “specimen or sample”, that a baby was placed in a mortuary space which was already occupied by an “unknown and unrelated adult”, a baby disposed of in clinical waste against the wishes of their parents, and another baby’s body kept in a domestic fridge in a bereavement room.
James Murray(Image: Wiktor Szymanowicz/Shutterstock)
Mr Murray told MPs: “The emotional and psychological effect of these dehumanising failures was to lay out the most profound disrespect on the most unbearable distress. There is also evidence that the trust actively decided not to report failings in mortuary care to families.”
He said he had asked NHS England to write to trusts to ensure failings are not repeated elsewhere.
He said the Human Tissue Authority will require all mortuaries to review internal records over the last decade to ensure all incidents have been logged and reported. They will have to report back by October 16.
Ethan BlackshawToday14:33 BST
Health Secretary James Murray has apologised on behalf of the NHS, which “catastrophically” failed families who “suffered so appallingly” under maternity services at Nottingham University Hospitals NHS Trust (NUH).
In a statement, he told the Commons: “The driving force behind this review has been the affected families themselves. They have demonstrated more patience, more courage and more tenacity than one might imagine is possible from those dealing with broken hearts that will never mend.
“And whilst each of their experiences unique, one feature is common: at the very moment that they were at their most vulnerable, they placed themselves and the lives of their unborn babies in the hands of the NHS, and the NHS failed them catastrophically.
“To all of those who have suffered so appallingly, I say today on behalf of the NHS, I am sorry.
“I am sorry, not just for the failures or the heartless and undignified treatment, but also because your cries of concern went unheard for too long.
“And so the Government will act. We will act by taking immediate steps, including to expand Martha’s Rule to all maternity in neonatal settings, so that parents can demand a second opinion if they feel their concerns are being ignored.”
Ethan BlackshawToday14:26 BST
By Martin Bagot, Health and Science Editor
The report today reveals a dysfunctional working environment on maternity wards, concluding there was a “bullying and toxic culture” at the trust over many years.
The review team heard how some staff members were “specifically and consistently mentioned as forming intimidating cliques that were/are well known, but not confronted or challenged.”
Staff “reported experiences shaped by longstanding cultural challenges, including hierarchy, bullying (particularly by some labour ward co-ordinators), nepotism and aggressive behaviour”.
Martin BagotToday13:59 BST
By Martin Bagot, Health and Science Editor
The review also examined 17 babies and one adult who died and what happened to them after death. It found “recurring examples of failure to protect the dignity of the deceased, including an early gestation baby disposed as clinical waste; dehumanising language by clinicians; and poor mortuary care, including failure to comply with legal requirements…”
On Monday, Nottinghamshire Police said two men had been arrested “in connection with operating practices in the mortuary service” provided by the trust.
Nottingham City Hospital’s maternity unit(Image: Tom Maddick / SWNS)
By Martin Bagot, Health and Science Editor
The catalogue of errors outlined in the report included failures in the monitoring of babies, a failure to recognise babies were in distress during labour and a failure to escalate cases to senior doctors. The report said: “In a number of cases these failures contributed to severe neonatal injury, stillbirth and neonatal death.”
Mothers were sent home with seriously ill babies as signs of poor feeding, hypoglycaemia, and infection were missed “leading to avoidable harm and, in some instances, death”.
Martin BagotToday12:56 BST
Donna Ockenden has paid tribute to the courage of a group of families who refused to be silenced and pledged that what had happened to them wouldn’t happen to anyone else. “Without them, this review would not exist,” she said.
Joe SmithToday12:41 BST
By Martin Bagot, Health and Science Editor
Donna Ockenden said: “The review team and I would like to express our deepest gratitude to the thousands of families, staff and community representatives who placed their trust in us and contributed to this review. Many shared the most painful chapters of their lives, speaking with extraordinary courage about experiences of trauma and grief.
“They did so not only in pursuit of answers for themselves, but in the hope that no other family would have to endure what they have experienced.”
Donna Ockenden, Chair of the independent review(Image: Joseph Raynor/ Nottingham Post)
By Martin Bagot, Health and Science Editor
The report says trust leaders oversaw a “culture of organisational denial” and knew there were serious issues going back in some cases before 2010, but failed to take action to prevent more deaths.
Managers were involved in a culture of bullying, ignored staff concerns and in some cases were rude and aggressive.
Ms Ockenden concludes that many of the systems of oversight established for maternity care in England “are no longer fit for purpose”. Her report states maternal deaths are at a 20-year high and its findings are likely to lead to national changes to care.
Martin BagotToday12:07 BST
By Martin Bagot, Health and Science Editor
In one signature case the report said parents were wrongly advised to terminate a healthy pregnancy due to a testing error.
Carly Wesson and her partner Carl Everson were expecting their first baby which they had nicknamed “Ladybird” before wrongly being told the foetus had a rare genetic condition. They were advised to consider termination by a foetal care consultant who said Ladybird would be left with severe care needs and might not survive the pregnancy.
They previously spoke about making the “impossible decision” to terminate the pregnancy at 14 weeks.
Investigations later showed Ladybird was a healthy baby.
The report said: “For Carly and Carl, the weight of their loss is inseparable from the fact that decisions made were based on misinformation.”
City Hospital in Nottingham, where the three babies died(Image: Tom Maddick / SWNS)