The largest maternity review in NHS history, led by Donna Ockenden, has today published its report into maternity and neonatal services at Nottingham University Hospitals (NUH) NHS Trust.
Alongside the report, around 2,500 families who contributed to the review will receive a personalised report into their care when their baby died.
Reading Donna Ockenden's report is absolutely heartbreaking. First and foremost we must keep those families impacted by what happened in Nottingham in our minds today.
There is also a lot of anger and frustration, when we hear that so many parents and families and their babies experienced such poor care, and were treated with a lack of kindness and compassion for so long.
These personal testimonies reveal trauma and pain that was compounded by families not being listened to or believed, and opportunities for lessons to be learned, ignored.
This was the opposite of what high-quality maternity care that treats parents as individuals looks like. Listening with belief and respect should be at the heart of the care given to families, regardless of who they are or what their background or ethnicity is.
The Nottingham families who have fought for accountability and justice cannot be let down again. It is clear that the Trust failed to provide the governance and leadership needed to keep women, birthing people, babies and families in Nottingham safe over many years.
With the national maternity and neonatal investigation in England due to report by the end of June, the Government must take the opportunity to completely reform the maternity and neonatal system.
- Clea Harmer, Chief Executive, Sands.
The Review has found that failures in maternity and neonatal services at NUH were deep-rooted, systemic and sustained over many years, with repeated missed opportunities for intervention.
It underscores that safe, high-quality care must focus on listening to women and families, embedding a culture of compassion and accountability, strengthening governance, and supporting staff.
Today, we have started the process of providing answers. We have set out clear findings and essential actions to address the concerns raised by families and staff.
These actions when implemented will drive improvement both within perinatal services at Nottingham University Hospitals NHS Trust and across England.
While the majority of births on the NHS are safe, too many families have suffered harm that should never have happened. Their experiences will drive real and lasting change to maternity services in England, driven by staff working to improve services.
- Donna Ockenden, Chair of the Independent Review.
Government responds to Ockenden report
The government has today confirmed they will be rolling out Martha’s Rule across maternity and neonatal wards in England to ensure every parent can request a rapid review from an independent medical team if a baby or mother’s condition is deteriorating and they are concerned this is not being responded to.
Those responsible for failures will be compelled to give evidence to investigations into failing maternity care to end a culture of secrecy and prevent further harm.
And reports of incidents in mortuaries across the country will also be more tightly reviewed, following the deeply concerning findings about the lack of respect given to deceased babies, and the complete disregard to their dignity.
The Human Tissue Authority will require all mortuaries to review internal records dating from 2015-2026 to ensure all incidents have been logged and reported.
We welcome 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.
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.
- Clea Harmer, Chief Executive, Sands.
Background on the Independent Review
The Review was agreed by the Rt Hon Sajid Javid MP when Secretary of State in May 2022, following concerns regarding the quality and safety of maternity services at NUH being raised by families in Nottingham who had suffered harm during their maternity journey.
The voices of bereaved and harmed families brought attention to mounting evidence of serious failings, including avoidable deaths, stillbirths, neonatal deaths and life-changing injuries to both babies and mothers.
The Review formally commenced on 1 September 2022, following considerable preparatory work and early engagement with families, and replaced a regional review after affected families called for greater independence and scrutiny.
Sands here to support
We know that reports into maternity services can be difficult for anyone who has experienced pregnancy or baby loss.
At Sands we understand that for some families, this will be the first time they will have received a fully independent review of their care when their baby died.
And I know how distressing this news will be to everyone in Nottingham and across the UK whose lives have been changed by pregnancy and baby loss.
I want all these parents and families to know Sands is here for you to offer trauma-informed bereavement support for as long as you need. You are not alone.
- Clea Harmer, Chief Executive, Sands.
With the Amos investigation also due to report this month, there may be increased media coverage around pregnancy and baby loss over the next couple of weeks. Please remember that you do not have to engage with this content and it is ok to step away from social media and take a break from the news.
Please know that we are here to support you whenever you need us.