Nottingham Maternity Services Review : What is the Ockenden Report?

We take a look at the latest independent inquiry headed by Donna Ockenden and answer some of the key questions surrounding this review.

Who is Donna Ockenden?

Donna Ockenden is an experienced and respected British midwife who has held several senior NHS leadership roles over her 30 year career. She was also the Chair of the England Royal College of Midwives between 2006 and 2014.

In 2016, she was appointed by the UK Secretary for Health & Social Care to chair an independent review into maternity services at The Shrewsbury and Telford Hospital NHS Trust, following growing concerns about mother and baby safeguarding.

The final report, known as The Ockenden Report, was published in March 2022 and revealed extensive and shocking maternity failings at The Shrewsbury and Telford Hospital NHS Trust.

Donna Ockenden and her independent inquiry team found that a total of 201 babies and nine mothers could have, or would have, survived if the NHS Trust had provided better care. A total of 600 cases of medical negligence were linked with the inquiry, some of which were also investigated by police.

As well as revealing the extent of the failings in mother and baby care, the report also showed that the Trust had neglected to learn from its clinical mistakes time after time, leading to further devastating cases that could have been avoided.

The report provided 60 recommendations for the Trust to improve and introduced four key pillars that it felt should form the foundation of all future maternity services by any NHS Trust in the UK. These are:

  • Safe staffing levels
  • A well-trained workforce
  • Learning from incidents
  • Listening to families.

What is the Nottingham Maternity Review – the next Ockenden Report?

In 2022, Donna Ockenden was asked to chair another independent maternity services review – this time looking into alleged failings at Nottingham University Hospitals NHS Trust, which runs both Nottingham City Hospital and Queens Medical Centre.

The inquiry will investigate alleged failings in the care of mothers and babies at the two sites and will be speaking to the families affected as part of the review.

The final report is expected in 2025 and investigations are on-going at the time of publishing.

Who is part of the Nottingham Maternity Review team?

Donna Ockenden leads a multidisciplinary team made up of experienced obstetricians, midwives, neonatologists, specialist doctors and medical experts from more than 20 Trusts across England. The team works within maternity services in the NHS on a daily basis and they understand what patient safety and quality care looks like.

Along with a large administration and legal team, they are investigating of all the alleged incidents and writing the report and recommendations.

What triggered the maternity services inquiry in Nottingham?

The inquiry into maternity services in Nottingham came about following growing concerns about mother and baby care and safety at Nottingham City Hospital and Queens Medical Centre. Over 100 families wrote to the UK Health Secretary sharing their experiences and voicing concerns.

There were also concerns from the Care Quality Commission (CQC) which said women and babies may not be safe unless significant and immediate improvements were made to maternity services at the Trust. Both sites were rated as inadequate overall in its last inspection.

How is the Nottingham Maternity Review progressing?

Donna Ockenden and her independent inquiry team have been speaking to the families affected since June 2022 and the review formally began in September 2022.

So far, more than 1,800 cases of possible harm to babies and mothers between 2010 and 2020 are being investigated and that number expected to grow before the review concludes. It looks set to be the biggest review into maternity services the UK has ever seen.

Over 700 members of staff from Nottingham University Hospitals NHS Trust have also come forward so far to help inquiry.

As more and more families came forward with new details came to light, the police announced their own criminal investigation into alleged failings at the Trust in September 2023.

Donna Ockenden is still encouraging families who have been affected to come forward and she’s expected to continue to take cases as part of the inquiry until around May 2025.

The final report is expected in September 2025. This will contain the inquiry’s findings and recommendations. It is anticipated to be another damning report pointing at systematic failings within maternity services.

What is our view on the Nottingham Maternity Review?

We see the devasting outcomes of medical negligence every day. We work with families whose lives, relationships, careers and health have been torn apart because of the poor care they, or a loved one, received. The results can be lifelong and all consuming.

Families deserve to know what went wrong and why. Crucially, these failings need to be made public so that measures can be put in place to stop it ever happening again. Needless to say, we welcome the latest inquiry into maternity care in Nottingham.

The review into maternity services at The Shrewsbury and Telford NHS Trust uncovered shocking and disturbing cases and exposed extensive systematic failings. Worse still, it showed that no-one learnt from those catastrophic mistakes and further failings that could have been prevented continued to happen.

Early indications are that the next Ockenden Report will show a worryingly similar trend in Nottingham. Our thoughts are with all of the families affected who will be bravely sharing their stories as they fight to get the answers they deserve and to stop it from happening to another family in the future.

How we can help

If you have concerns about treatment provided at Nottingham University Hospitals NHS Trust, or maternity care in general, and would like to speak with one of our medical negligence specialists, call us for a free consultation on 02920 391773 or contact Rachel Kirby by email at

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