Nottingham Maternity Report 2026: The key findings, statistics and what happens next

The independent review into maternity and neonatal services at Nottingham University Hospitals NHS Trust, led by senior midwife Donna Ockenden, is the largest investigation into NHS maternity services ever conducted.

The review examined more than 2,500 family cases involving maternity and neonatal care at Queen’s Medical Centre (QMC) and Nottingham City Hospital, both run by Nottingham University Hospitals (NUH) NHS Trust, between 2012 and 2025. As well as families, more than 830 current and former staff also provided evidence.

The final report, published on 24 June 2026, concluded that hundreds of mothers and babies experienced potentially avoidable harm and death because of long-standing failures in maternity care, leadership, governance and organisational culture at the trust.

A key finding was that many deaths and life-changing injuries could potentially have been prevented if concerns had been recognised earlier and women had been listened to. It also concluded that these failures persisted over many years despite repeated opportunities to improve.

What did the Nottingham maternity report find?

The review found widespread systemic failings across maternity services in Nottingham, including:

• Women and families were too often not listened to when raising concerns.
• Warning signs of maternal and fetal deterioration were missed or dismissed.
• Delays in diagnosis, escalation and emergency treatment contributed to avoidable harm.
• Serious incidents were not always investigated properly, preventing learning and improvement.
• Chronic staffing shortages, poor leadership and a culture of bullying affected patient safety.
• Health inequalities, including racism and stereotyping, contributed to poorer outcomes for some women.

Key statistics from the Nottingham Ockenden Report

The report concluded that there were 162 potentially avoidable deaths at Nottingham University Hospitals NHS Trust from 2012 to 2025, including:

• 94 stillbirths
• 62 neonatal deaths
• 6 maternal deaths

It also identified that 444 women and 76 babies experienced potentially avoidable harm. This included:

• 142 fourth-degree perineal tears for mothers
• 130 unexpected maternal intensive care admissions
• 115 cases of major obstetric haemorrhage for mothers
• 76 cases of severe pre-eclampsia
• 105 babies with brain injuries
• 9 children considered likely to have developed cerebral palsy because of poor care

What went wrong with Nottingham’s maternity care?

Donna Ockenden identified recurring themes throughout the investigation, including:

• Failure to recognise reduced fetal movements.
• Poor interpretation of fetal heart monitoring (CTG).
• Delays performing emergency Caesarean sections.
• Failure to escalate concerns to senior clinicians.
• Poor communication between maternity and neonatal teams.
• Inadequate staffing and excessive workloads.
• Failure to investigate previous incidents and learn lessons.

One of the strongest messages in the report is that women repeatedly reported symptoms or concerns before serious harm occurred but were too often ignored, reassured incorrectly or told their symptoms were normal.

What did the Nottingham maternity report say about neonatal care?

Although neonatal services also required improvement, the review found neonatal care was generally stronger than maternity care.

Many babies who later died or suffered brain injuries had already experienced oxygen deprivation before birth because of failures during pregnancy or labour.

However, the report did identify that 76 neonatal cases involved significant or major concerns in care, and 62 neonatal deaths were potentially avoidable.

The main neonatal failings identified were:

• Delays in recognising deterioration after birth or in escalating concerns quickly enough
• Problems with neonatal resuscitation, including delays and a lack of preparation
• Communication failures between maternity and neonatal teams
• Poor documentation
• Understaffing issues

What recommendations did the Nottingham Ockenden Report make?

The report makes 18 immediate and essential actions designed to improve maternity safety across England.

Key recommendations include:

• Listening to women and families throughout pregnancy and labour.
• Improving staffing levels and workforce planning.
• Strengthening leadership and organisational culture.
• Better multidisciplinary training.
• Improving investigations following serious incidents.
• Tackling health inequalities.
• Improving governance and accountability across maternity services.

Following publication of the report, NHS England also confirmed that Martha’s Rule—a patient safety initiative allowing patients and families to request an urgent independent clinical review if they believe concerns are not being acted upon—will be extended to all maternity and neonatal services in England.

Why is the Nottingham maternity report important?

The independent Nottingham Maternity Review is one of the most significant patient safety investigations ever undertaken by the NHS. Beyond documenting the devastating experiences of thousands of families, it highlights systemic problems that exist beyond these two hospitals. These issues have national significance.

It highlights recurring NHS issues – including failures to listen to women, delayed recognition of deterioration, poor communication, inadequate staffing and weak leadership – that have been repeatedly identified in other maternity investigations across England, including Donna Ockenden’s earlier independent report into maternity services in Shrewsbury and Telford Hospital NHS Trust in 2022.

The Nottingham report’s recommendations are intended to drive improvements across all NHS maternity services, influencing policy, patient safety initiatives such as the national rollout of Martha’s Rule, workforce planning, clinical training and governance to help prevent similar tragedies in the future.

Its findings are expected to shape maternity policy, clinical practice and patient safety initiatives across England for years to come, with a renewed focus on listening to women, recognising deterioration earlier and ensuring that concerns raised by families are acted upon promptly.

If you have any concerns regarding the maternity care that you or a loved one has recieved, please get in touch with our maternity negligence team below.