When Donna Ockenden was appointed to lead the independent review into maternity services at Nottingham University Hospitals NHS Trust, thousands of families hoped they would finally get answers about the care they had received.
In our previous update on the Ockenden Maternity Services Investigation, we looked at how the review had grown into the largest maternity inquiry in NHS history and the concerns that had prompted it. Since then, Donna Ockenden has published her final report, bringing together the experiences of more than 2,500 families and setting out the findings of a review spanning more than a decade of maternity care.
For many families, this marks an important milestone. While the report cannot undo the harm that has been suffered, it provides independent recognition of the failings that occurred and outlines the changes needed to help prevent similar tragedies in the future.
What is the final Ockenden Report?
The Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust was commissioned to examine maternity and neonatal care provided between 2012 and 2025.
Led by Donna Ockenden, the review looked at more than 2,500 families’ experiences and assessed over 2,000 clinical cases to determine whether the care provided met the expected standard and whether different treatment might have changed the outcome.
The report concludes that the problems identified were not simply the result of individual mistakes. Instead, it found repeated failings over many years involving leadership, governance, staffing, communication and patient safety.
What did the report find?
The report identifies a number of recurring problems across the maternity service, many of which had already been highlighted in earlier reviews but had not been fully addressed.
Among its key findings are:
• women and families were not always listened to when they raised concerns
• staffing shortages placed increasing pressure on maternity services
• opportunities to recognise and respond to complications were sometimes missed
• serious incidents were not always investigated effectively
• lessons from previous incidents were not consistently acted upon
• poor leadership and organisational culture contributed to failures in patient safety
The review also found that around one in five maternity cases reviewed involved significant concerns where different management might reasonably have made a difference to the outcome.
Importantly, the report also recognises that improvements have been made in recent years. Changes to leadership, governance and clinical practice have begun to address some of the long-standing issues, although it is made clear that further work is needed to ensure those improvements are maintained.
Families’ voices helped bring these failings to light
One of the strongest messages running throughout the report is the importance of listening to families.
Many parents described feeling that their concerns were dismissed during pregnancy or labour, or that they were not properly involved in decisions about their care. Others spoke about the difficulties they faced trying to get answers after something had gone wrong.
The report recognises the devastating impact that poor maternity care can have on mothers, babies and their wider families, as well as the additional distress caused when investigations are delayed or communication is poor.
It is because so many families continued to ask difficult questions and share their experiences that this review was able to identify patterns of failings that may otherwise have remained hidden.
What does the report mean for families now?
For some families, the publication of the final report may provide long-awaited acknowledgement of what they have experienced. For others, it may raise new questions about whether the care they or their baby received met an acceptable standard.
Although the report itself does not determine compensation or legal liability in individual cases, it may encourage families to seek independent advice where concerns remain.
Every medical negligence claim is assessed on its own facts. A solicitor will usually obtain the relevant medical records and seek independent expert evidence to establish whether the care fell below an acceptable standard and whether that contributed to the injury or outcome.
There are time limits for bringing medical negligence claims, although these vary depending on the circumstances. If you have concerns about maternity care you or your child received, it is generally sensible to seek legal advice sooner rather than later.
What happens next?
The report sets out a series of Immediate and Essential Actions designed to improve maternity care, not only at Nottingham University Hospitals NHS Trust but across maternity services in England.
These recommendations focus on improving patient safety, ensuring women are listened to, strengthening leadership, improving clinical training and creating a culture where concerns are identified and acted upon before avoidable harm occurs.
Alongside these recommendations, other investigations into maternity services at the Trust continue, including the ongoing police investigation known as Operation Perth.
While the publication of the report represents the end of the independent review, it is unlikely to be the end of the story. Families, healthcare providers and regulators will all be looking closely at how the report’s recommendations are implemented in the years ahead.
Seeking answers after maternity failures
No report can change what families have already experienced, but it can provide recognition that failings occurred and help drive improvements for future patients.
For some families, seeking legal advice is also an important step. A medical negligence claim can help establish what happened, whether the care provided fell below an acceptable standard and, where appropriate, secure financial support for ongoing treatment, rehabilitation or lifelong care needs.
At Bridge McFarland, our specialist medical negligence solicitors have supported many families affected by failures in maternity care. We understand that taking legal action can feel daunting, particularly after such a traumatic experience. That’s why many of our medical negligence claims are handled on a No Win, No Fee basis, meaning you can seek expert legal advice without the worry of paying legal fees upfront.
If you have concerns about the care you or your baby received, we’re here to discuss your options and explain whether you may be able to bring a claim.
To find out more call us on 0800 987 8800 or email medneg@bmcf.co.uk for a free, no obligation consultation.