The publication of the long-awaited Ockenden Review into maternity services at Nottingham University Hospitals NHS Trust (NUH) has been described as a pivotal moment for patient safety in England, with legal experts urging healthcare leaders to ensure its findings lead to lasting improvements for mothers, babies and families.
The independent review, led by Donna Ockenden, examined maternity care provided by NUH between April 2012 and May 2025. Originally expected to investigate around 1,700 cases, the review expanded to include approximately 2,500 families, making it the largest maternity investigation ever undertaken within the NHS.
For many families, the report represents years of campaigning, testimony and determination to ensure their experiences were heard. It examines some of the most serious outcomes in maternity care, including stillbirths, neonatal deaths, maternal deaths and cases involving severe maternal harm or serious birth injuries.
Claire Cooper, (PICTURED) Senior Associate Solicitor specialising in medical negligence at Rothera Bray, said the report's publication is both emotional and significant for those affected.
"Many families have shown immense courage in speaking out about their devastating experiences," she said. "Families need to know that their experiences will lead to change. That means better communication, safer systems and a culture that listens to concerns and acts on them, Claire told That's Health.
The review paints a troubling picture of long-standing concerns within the Trust. According to the report, warning signs relating to staffing, leadership, organisational culture and patient safety were identified as far back as 2007. Despite a series of reviews and interventions over the following years, many of these issues persisted.
Among the concerns highlighted by Donna Ockenden were insufficient staffing levels, difficulties accessing essential training, failures to listen to parents' concerns and a culture that sometimes discouraged staff from speaking up.
Importantly, the report does not simply look back at what went wrong. It also sets out 18 Immediate and Essential Actions designed to improve maternity care across England. These recommendations include strengthening communication with families, improving workforce planning, enhancing maternity record keeping, supporting staff training and ensuring concerns can be escalated quickly through measures such as Martha's Rule.
Healthcare leaders are now being urged to act swiftly to implement these recommendations.
The review team has emphasised that safe, compassionate and equitable maternity care is achievable, but only through sustained commitment to accountability, transparency and learning.
For families involved in the review, individual feedback reports will be issued between June and December 2026, providing greater clarity about the care they received. Some families will also be offered meetings to discuss their findings in more detail.
While the report cannot undo the pain experienced by affected families, many hope it will mark the beginning of meaningful change across NHS maternity services.
The ultimate goal, campaigners and healthcare professionals agree, must be to ensure that every mother, baby and family receives the safe, respectful and compassionate care they deserve.






















