Nottingham Maternity Scandal: Inquiry Bares Devastating Babies’ Deaths and Avoidable Errors


The independent inquiry into the maternity scandal at Nottingham University Hospitals NHS Trust has released its findings, uncovering a litany of devastating failures and avoidable errors that have caused many unnecessary deaths and injuries to mothers and babies.

The inquiry, led by independent senior midwife Donna Ockenden, explored the experiences of 636 families who had used the trust’s maternity services between 2010 and 2019.

**Key Findings**

**1. High Death and Injury Rates:**

– The review revealed significantly higher rates of babies dying during or soon after birth and mothers suffering severe injuries compared to national averages.

**2. Missed Opportunities:**

– Missed opportunities to diagnose and treat conditions such as fetal distress, pre-eclampsia, and sepsis contributed to preventable deaths and serious harm.

**3. Poor Staffing and Resources:**

– The report cited inadequate staffing levels, a lack of specialist expertise, and limited access to equipment as major contributing factors to the failures.

**4. Culture of Blame:**

– The inquiry found a prevalent culture of blame and intimidation among staff, hindering open reporting and learning from mistakes.

**5. Lack of Patient-Centered Care:**

– The report criticized the absence of a patient-centered approach, with families feeling unheard and ignored by the hospital staff.


– Increase staffing levels and ensure adequate training for all maternity staff.
– Improve access to specialist expertise and equipment.
– Foster a positive culture that promotes open communication and learning from mistakes.
– Establish a system to track and respond to patient concerns and complaints effectively.
– Provide better support and care coordination for families throughout their maternity journey.


The NHS Trust has welcomed the inquiry’s findings and apologized for the devastating impact on the affected families. It has pledged to implement all recommendations and make necessary changes to improve the quality and safety of its maternity services.


The Nottingham Maternity Scandal is a tragic reminder of the devastating consequences that can occur when maternity services fail. The inquiry’s findings have shed light on the systemic failures and cultural issues that contributed to the avoidable deaths and injuries. The recommendations laid out in the report provide a roadmap for significant improvements to ensure such a tragedy is never repeated..

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