The Nottingham maternity report, investigating 2,500 families, is published this week. The independent inquiry, led by senior midwife Donna Ockenden, is the largest of its kind in the UK, examining stillbirths, neonatal deaths, maternal deaths and cases of severe injury to babies or mothers at Nottingham University Hospitals NHS Trust (NUH) between April 2012 and May 2025. Its publication, originally expected in September 2025, was delayed by nine months to allow for the inclusion of up to 300 additional cases and to ensure every review met the highest professional standards. For the families who have campaigned for more than a decade, it is a landmark moment — but also a deeply traumatic one.
The families’ stories: preventable tragedies
The report details a catalogue of failures that devastated hundreds of families. Wynter Andrews died in 2019 at Queen’s Medical Centre from hypoxic ischaemic encephalopathy — a loss of oxygen to the brain — which could have been prevented had staff delivered her earlier. Her mother, Sarah Andrews, said she was told to stay at home for six days despite contractions and signs of infection. When an emergency caesarean was finally performed, the smell of infection filled the room; Wynter was stuck in her pelvis. Staff failed to resuscitate her for 23 minutes. “They said it was one of those things, that sometimes babies die,” Sarah recalled. “One said to us: ‘If we listen to every mother’s concerns, we’d be overrun.’” A year later, a coroner ruled it a clear case of neglect. The trust later pleaded guilty to failing to provide safe care and treatment to Sarah and Wynter, resulting in a fine of £800,000.
Felicity Benyon, then 29, underwent an emergency hysterectomy at Queen’s Medical Centre after giving birth in 2015. During the procedure, medics accidentally removed her bladder, leaving her with a urostomy bag. She was told the placenta accreta had completely enveloped her bladder — but a subsequent investigation found the placenta had not touched it at all. “It should have just been a hysterectomy and then home, instead of living with lifelong complications,” she said. “I don’t feel safe in hospitals. But that’s the place you’re supposed to feel safe because it’s where you’re at your most vulnerable.”
Caitlin Stringer was born prematurely in 2021 at Nottingham City Hospital. At 30 days old she developed necrotising enterocolitis (NEC), a life-threatening gastrointestinal emergency. Her parents said they repeatedly raised concerns about her distended abdomen, lethargy and feeding difficulties — all red-flag signs of NEC — but staff addressed each concern in isolation. An external review commissioned by the trust later found that an X-ray had diagnosed NEC 15 hours before Caitlin collapsed, yet she was not given antibiotics within the required hour. She suffered a severe brain injury. Caitlin now has cerebral palsy and is expected to die in childhood; last year she was in paediatric intensive care 13 times. “This review feels like the validation that I never wanted,” her mother, Emily, said.
Quinn Parker died at Nottingham City Hospital 36 hours after his birth in 2021. His mother, Emmie Studencki, had attended hospital four times with bleeding in late pregnancy; she said her requests for a caesarean were ignored. When a doctor eventually broke her waters, the bed was covered in blood. Quinn was found to have brain damage. Paramedics had noted concerns about a rigid abdomen and blood loss of over a litre, but those notes were not collected properly by the hospital. Quinn was one of three babies whose avoidable deaths led to NUH being fined £1.6 million by the Care Quality Commission — the largest maternity-related penalty the regulator has ever issued. “You think you’re in the best place at the time,” his father, Ryan Parker, said. “What is really happening is Quinn is just slowly dying but no one’s doing anything.”
Harriet Hawkins was stillborn at Nottingham City Hospital in April 2016 after her mother had been in labour for six days. An external review identified 13 failures and concluded her death was almost certainly preventable. Her mother, Sarah Hawkins, said the trust took 159 days to log the incident as a serious case — and for three years tried to blame an infection. “For so long in Nottingham we were made to feel like the mad grieving parents,” she said. “It just felt like a complete cover-up.”
Systemic failures and a toxic culture
The Ockenden review is expected to highlight deep-rooted systemic problems that extend far beyond individual errors. Investigations into previous maternity scandals — including the Ockenden review at Shrewsbury and Telford Hospital NHS Trust, which uncovered 201 baby deaths and nine maternal deaths — have repeatedly pointed to a failure to investigate, learn and improve over two decades. In Nottingham, former staff have reported a belief that the trust had a “superior” way of working, which led to a failure to act on duty of care. Allegations include racism towards mothers, staff encouraging women to stay at home, and using offensive shorthand for patients.
Understaffing has been a persistent issue. Despite some improvements, challenges remain in midwife numbers and other essential roles. The Care Quality Commission has repeatedly rated NUH’s maternity services as “requires improvement” or “inadequate” in recent years. Calls have been made for regulatory bodies — the General Medical Council, the Nursing and Midwifery Council, and the CQC itself — to be investigated for their handling of previous concerns. The GMC is currently reviewing 62 maternity cases in Nottingham but has been accused of denying knowledge of certain doctors involved.
The broader context is a national crisis in maternity care. Maternal deaths are at a 20-year high. Reports indicate rising rates of stillbirths and neonatal deaths, despite hundreds of recommendations from previous inquiries. The Nottingham Maternity Families Group has urged the government to hold a statutory public inquiry into maternity care across England. The government’s maternity adviser, Michelle Welsh, has acknowledged that Ockenden’s inquiry cannot legally compel witnesses to testify. Meanwhile, Nottinghamshire Police continue their investigation, Operation Perth, examining care provided to at least 200 families, with corporate manslaughter being considered as a potential charge.
Trust’s response
Anthony May, chief executive of Nottingham University Hospitals NHS Trust, said: “I want to pay tribute to the bravery of the many families who have worked tirelessly to get answers and to make maternity services safer for others. I have met some of the affected families, and they have shared their painful and life-changing experiences with me, for which I am very grateful. I am very sorry for the pain and suffering these families have endured.” He added that NUH staff had “shown their commitment to change” and that the trust would “consider carefully what we need to do next to ensure that we learn from what happened in the past and to continue to improve maternity services.” Ockenden herself has committed to overseeing improvements at NUH for approximately two years after the report’s publication.