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The Ockenden Report, published on 24 June 2026, lays bare the human cost of systemic failure. It examines maternity services at Nottingham University Hospitals NHS Trust (NUH) over more than a decade, making it the largest inquiry of its kind in NHS history. More than 2,500 families came forward to share their experiences [Acknowledgements, p. iii].

The findings are shattering. For years, warning signs were ignored. Staff shortages were chronic. A culture of bullying silenced those who tried to speak up. The Trust’s board disengaged from front‑line reality, and governance processes systematically downgraded serious incidents rather than learning from them [Staff Voices, pp. 96–99; Clinical Governance, pp. 272–280]. Women and their babies were harmed, sometimes fatally, while their concerns were dismissed.

The Signature Case of baby Harriet Hawkins makes this failure personal. Her avoidable stillbirth in 2016 was followed by almost a decade of institutional obfuscation [Signature Case, p. 39]. Yet Harriet’s story is only the most visible thread. Across the report, the same fractures recur: women turned away during labour, abnormal fetal heart traces ignored, postpartum haemorrhages not escalated, and bereaved families met with defensiveness rather than honesty.

This article does not attempt to repeat every finding. Instead, it traces how the system became the pathogen. It shows how failures in culture, leadership, staffing, and governance combined to create an environment in which safe care became impossible. The following sections examine the organisational disease that allowed harm to flourish, and why the lessons of Nottingham must now drive enduring change across the NHS.

The Preventable Death That Shouldn’t Have Happened

Baby Harriet Hawkins was stillborn at Nottingham University Hospitals on 16 April 2016. She was full‑term and healthy. Her death was avoidable. The care her mother, Sarah, received in the final days of pregnancy and during labour fell far below acceptable standards [Signature Case, p. 39].

A Family Let Down by the System

Sarah and her husband Jack were both senior healthcare professionals working at the Trust. When Sarah went into labour, she made repeated telephone calls to the maternity unit. She was suffering increasingly painful contractions. Several of those calls were not recorded in hospital documents. Each time, she was told she was “not in labour” and was advised to stay at home [Signature Case, p. 39].

The unit operated a local guideline that women should be invited in for assessment after calling three times. Staff twisted that safety net into a barrier. In practice, women were required to call three times before they would be allowed in [Signature Case, p. 47].

Gatekeeping and a Culture of Denial

Sarah was not alone. Many staff told the Review that a culture of gatekeeping had taken hold. Women in early labour were “the least prioritised,” and there was “pressure to make women in the latent phase normal” [Signature Case, pp. 48–49]. One staff member described the practice as “coerce them into going home” [Signature Case, p. 54].

The unit was severely understaffed. Labour‑ward coordinators acted as gatekeepers, discouraging admissions to manage workload. Midwives who challenged this culture were ignored or bullied [Staff Voices, pp. 96–99].

Missed Opportunities and a Preventable Death

On 17 April 2016, after days of contractions, Sarah was finally admitted. She was 9 cm dilated. Harriet’s heartbeat could not be found. An ultrasound confirmed the worst: intrauterine death. The Review Team later identified nine missed opportunities in care. If any one of them had been taken, Harriet would most likely have survived [Signature Case, p. 39].

The Aftermath: Obfuscation and Delay

After Harriet’s death, the Trust’s response compounded the family’s trauma. An internal investigation, conducted without the parents’ input, incorrectly attributed the death to infection. The incident was not declared a Serious Incident. It took a fourth external review, published 19 months later, to conclude that Harriet had died from a sudden hypoxic event during a prolonged, obstructed labour. The review identified multiple failings in monitoring and escalation [Signature Case, pp. 40–466].

The Hawkins family’s fight for truth exposed a pattern of defensive institutional behaviour. Drafts of investigation reports were altered to soften criticism. A recording of Jack’s distressed phone call was later played at a management meeting without his knowledge. The family endured almost a decade of what the report calls “obfuscation, delay, callousness and incompetence” [Executive Summary, point 9, p. x].

One Thread in a Wider Pattern

Harriet’s death was not an isolated tragedy. It was the direct consequence of a broken system. Staff were too few and too afraid to speak up. Leaders normalised risk and silenced dissent. Governance processes buried mistakes rather than learning from them. The same failures that ended Harriet’s life run through hundreds of other cases in this report. Her story is the most visible thread of a systemic disease that the following sections will explore in detail.

The Board That Looked Away

A Pattern of Reassurance Over Scrutiny

Between 2012 and 2022, the Nottingham University Hospitals board received repeated assurances from senior executives that maternity services were safe and outcomes were good. These comforting messages came even as serious incidents accumulated and families were being failed [Corporate Culture, Governance & Leadership, p. 261 (upper)].

The board was told that challenges were no greater at NUH than at any other large teaching trust. Executives regularly argued that criticism from regulators such as the Care Quality Commission was unfounded or overstated. This culture of reassurance over scrutiny meant that deep problems were never truly confronted at the highest level [Corporate Culture, Governance & Leadership, p. 261 (mid)].

Six Reviews and No Action

Between 2015 and 2022, the Trust commissioned no fewer than six external reviews into maternity culture, governance, and safety. Every one of them identified serious problems: toxic culture, bullying, poor leadership, under‑staffing, and dysfunctional governance [Corporate Culture, Governance & Leadership, p. 262 (lower)].

The 2015 external review of City Hospital’s maternity unit uncovered a destructive culture of intimidation. The board was informed, but members were assured that there were “no problems with practice and clinical outcomes are good” [Corporate Culture, Governance & Leadership, p. 261 (mid)].

In 2018, an external review by MSB Consultancy found poor leadership, disempowered staff, and an environment where inappropriate behaviour was tolerated. Staff described the review as “the last throw of the dice” [Clinical Governance, p. 273 (upper)]. The board received a summary but did not drive the deep change that was needed. The report’s recommendations were never fully implemented [Corporate Culture, Governance & Leadership, p. 263 (mid)].

In 2022, a review of neonatal services by Ibex Gale painted a picture of bullying, favouritism, and staff feeling unsupported. Again, the findings were noted but not met with the urgency they demanded [Corporate Culture, Governance & Leadership, p. 264 (upper)].

The Review Team concluded that had these reports been acted upon, “undoubtedly many families’ experiences and outcomes would have been different” [Corporate Culture, Governance & Leadership, p. 262 (lower)].

A Disconnect Between Ward and Board

Staff on the ground knew the service was in crisis. In 2018, more than fifty midwives at the Queen’s Medical Centre signed a letter to the chair of the board, warning that staffing levels were dangerously low and patient safety was at risk [Staff Voices, p. 98 (mid)].

That letter was never discussed at a formal board meeting. The response came from the divisional director, not from the chair or chief executive. Staff described feeling “fobbed off” and that their warnings were ignored [Corporate Culture, Governance & Leadership, p. 254 (mid)]. The board did not see the letter, and it did not prompt any visible board‑level inquiry.

This disconnect was not accidental. Senior midwifery leaders had no direct access to the board. Maternity concerns were filtered through layers of management that often diluted or dismissed them. As one senior leader later acknowledged, “there was a disconnect between strategic direction and operational management” [Executive Summary, point 69, p. xv].

A Board Without Curiosity

Board members did not ask the difficult questions. When maternity issues did reach the Quality Assurance Committee, the discussion rarely led to deep challenge. Minutes show that the board accepted assurances that problems were being dealt with, without demanding evidence that real change was happening [Corporate Culture, Governance & Leadership, p. 262 (mid)].

Executives presented action plans and improvement programmes, and the board noted them without tracking whether they were actually implemented. A significant backlog of serious incidents, repeated failures in duty of candour, and poor cultural indicators were all visible but did not trigger sustained board attention [Clinical Governance, p. 272 (lower) and p. 273 (mid)].

The board’s focus was often elsewhere: financial performance, A&E waiting times, and ambitious strategic projects. Maternity was not a standing board agenda item until 2020 and did not receive substantive attention until after the damning CQC inspection of 2021 [Corporate Culture, Governance & Leadership, p. 261 (lower)].

The Cost of Looking Away

While the board looked away, women and babies suffered. Harriet Hawkins died in 2016 after a prolonged, obstructed labour that was mismanaged and ignored. Her death was not brought to the board. The pattern of harm continued year after year, with similar failures repeated in antenatal, intrapartum, and postnatal care [Signature Case, p. 39 (lower) and p. 66 (mid)].

It was only in 2020 when the CQC rated maternity services as “inadequate” and the Trust was placed in special measures, that the board finally began to give maternity the attention it had needed for a decade. By then, hundreds of families had already been let down [Corporate Culture, Governance & Leadership, p. 265 (lower) and p. 266 (upper)].

A Culture of Fear and Silence

A Climate of Bullying and Intimidation

A bullying and toxic culture was a long‑running and deeply embedded feature of maternity services at Nottingham University Hospitals. Among staff who responded to the Review’s survey, 38 per cent had witnessed or personally experienced bullying. Among those interviewed in depth, the figure rose to 44 per cent [Staff Voices, p. 101 (upper)].

The behaviour was not hidden. Staff repeatedly described a dominant clique of labour ward coordinators who used their power to intimidate, allocate workloads unfairly, and silence anyone who questioned them. Newly qualified midwives were given the most complex cases while friends received simpler allocations. A former staff member recalled being told on her second day that they would “break her” [Staff Voices, p. 102 (mid)].

External reviews confirmed what staff had been saying for years. A 2018 performance audit found that inappropriate behaviour was tolerated and that some staff viewed the review itself as “the last throw of the dice” [Clinical Governance, p. 273 (upper)]. A 2022 review of neonatal services painted a picture of bullying, favouritism, and staff feeling unsupported [Corporate Culture, Governance & Leadership, p. 264 (upper)].

Staff Afraid to Speak Up

Fear was the natural consequence. Staff described being “too scared to escalate” concerns, even when they knew patient safety was at risk. Junior midwives and doctors reported feeling intimidated and unsupported. One staff member said that raising a concern about a colleague “doesn’t get acted on, trying to protect people’s feelings, nobody wants conflict” [Staff Voices, p. 102 (lower)].

The Freedom to Speak Up Guardian role did not provide an effective safety valve. One post‑holder told the Review that their role felt “totally toothless” and that nothing happened after concerns were raised. A midwife who flagged safety issues was shut down by managers [Staff Voices, p. 114 (mid)].

The absence of psychological safety meant that problems were buried rather than resolved. Staff reported that Datix incident reports were submitted, but they rarely led to visible change. The experience, as one person put it, was that managers were “impenetrable” and “nothing ever got through to them” [Staff Voices, p. 108 (upper)].

The Gatekeeper Culture on Labour Ward

The toxic dynamics were at their most visible on the labour ward, where a small group of coordinators controlled access to care. Women in early labour were routinely turned away or discouraged from attending. Staff described a culture of “gatekeeping” that was driven by workload pressure but enforced through intimidation. One midwife recalled being pressured to “coerce them into going home” [Signature Case, p. 54 (mid)]. Another said that “there was a lot of pressure to make women in the latent phase normal” [Signature Case, p. 54 (upper)].

Midwives who tried to advocate for women were ignored or bullied. A staff member noted that coordinators were “toxic” during shifts when major incidents occurred, and that the culture was “cruel to women” [Intrapartum Care, p. 157 (lower); Staff Voices, p. 151 (lower)]. The effect was that women were left in pain and distress, and opportunities for timely intervention were repeatedly missed.

Leadership That Looked the Other Way

The culture of fear and silence was not confined to the labour ward. It was sustained by a leadership that failed to act on repeated warnings. Between 2015 and 2022, six external reviews into maternity services identified bullying, poor culture, and dysfunctional governance. Each time, the Board was told that problems were being addressed, but the underlying behaviours did not change [Corporate Culture, Governance & Leadership, pp. 265‑267].

In 2018, more than fifty midwives signed a letter to the Chair of the Board warning that staffing levels were dangerously low and patient safety was at risk. The letter was never discussed at a formal Board meeting. Staff felt “fobbed off” [Corporate Culture, Governance & Leadership, p. 254 (mid)]. The disconnect between the Board and the front line was total.

The Cost of Silence

When staff are afraid to speak up, women and babies are harmed. The Review found that failures to escalate, failure to challenge poor practice, and a normalisation of unsafe behaviours were direct consequences of the prevailing culture. As one staff member observed, “in a harsh working environment you survive by becoming hard” [Psychological Impacts, p. 89 (mid)]. The system rewarded compliance, not courage. The silence that protected the unit’s reputation ultimately cost families their safety.

Running on Empty – Chronic Under‑Staffing as the Accelerator of Every Safety Failure

A Service in Crisis Mode

Staffing levels were the single most pressing issue raised by those who worked in maternity services at Nottingham University Hospitals. In the Review’s staff survey, only 11 per cent of respondents reported that there were enough staff for the workload. Well over half – 59 per cent – said that staff regularly worked longer hours than was best for the quality of care. Almost three‑quarters, 73 per cent, told us they regularly worked in crisis mode, staying late because they believed it was the only way to keep patients safe [Staff Voices, p. 97 (mid)].

These figures were far worse than the national NHS average. They describe a workforce stretched beyond its limits day after day, week after week. One midwife recalled that during a twelve‑hour shift she had “no breaks” and was “caring for two women in labour at the same time with no support” [Staff Voices, p. 98 (lower third)].

Missed Training and Missed Care

Under‑staffing did not only mean exhausted clinicians. It meant that mandatory training was regularly cancelled because staff could not be spared from the wards. Midwives reported being pulled from CTG and emergency skills days so often that they were told to bring their uniforms “just in case” [Staff Voices, p. 108 (upper)]. Compliance with essential training fell, and the Clinical Negligence Scheme for Trusts safety standards could not be met. One staff member said their mandatory training was “out of date for years” [Clinical Governance, p. 316 (upper)].

The knock‑on effect on patient care was direct. On understaffed wards, observations were missed, escalation was delayed, and women were left without timely attention. The Review found repeated cases in the postnatal period where mothers who were becoming unwell waited hours for a review, while babies with feeding difficulties or jaundice were not seen face‑to‑face. In some of those cases the consequences were severe and irreversible [Postnatal Care, pp. 204‑205].

The Gatekeeper Effect

Staff shortages did not simply make work harder; they changed the way women were treated. Labour‑ward coordinators, who were meant to be supernumerary and provide oversight, were instead drawn into direct clinical care and used their remaining authority to discourage admissions. Midwives described a culture of gatekeeping – “there was a lot of pressure to make women in the latent phase normal” – and told us that women were often “coerced into going home” rather than being invited in for assessment [Signature Case, p. 54 (mid)].

The case of Sarah Hawkins, forced to call the unit repeatedly before being allowed in, was not an isolated tragedy. It was the predictable outcome of a system in which the number of beds and the number of staff dictated who received care, rather than clinical need [Signature Case, pp. 47‑54].

Staff Burnout and Moral Injury

The emotional toll on staff was enormous. Many described leaving work feeling they had “disappointed women on every shift” [Staff Voices, p. 98 (lower third)]. One staff member who left the Trust told us they had been “broken” by the experience. Another said that everyone was “just frazzled” and that many welcomed the 2020 CQC rating of inadequate because they felt someone was finally listening [Staff Voices, p. 98 (mid)].

The chronic short‑staffing created a vicious circle: as morale fell and sickness absence rose, the remaining staff were placed under even greater pressure. Bank and agency staff were used to plug gaps, but they were often unfamiliar with local guidelines, placing further strain on the substantive workforce [Staff Voices, p. 98 (upper)].

Board Awareness, Inaction

This was not a hidden crisis. Staff raised the issue repeatedly, with management, with the division, and directly with the Board. In 2018, more than fifty midwives at the Queen’s Medical Centre put their names to a letter to the Chair of the Trust Board, warning that staffing levels were dangerously low and patient safety was at risk [Staff Voices, p. 98 (mid)].

The letter was never discussed at a formal Board meeting. The response came from the divisional director, not from the Chair or the Chief Executive. Staff felt “fobbed off” [Corporate Culture, Governance & Leadership, p. 254 (mid)]. The disconnect between the Board and the front line was complete, and the lesson for those midwives was clear: raising concerns was pointless.

A Governance System That Didn’t Learn

Incidents That Were Never Seen

For more than a decade, a significant number of patient safety incidents in Nottingham’s maternity services were either never reported or were graded so low that they escaped proper scrutiny. The Review found over 100 cases involving significant or major concerns in care – grade 2 or 3 on the clinical grading scale – that had no corresponding incident report at all [Clinical Governance, p. 276 (mid)]. These were missed opportunities. They were not investigated, not learned from, and the families involved were never told.

When incidents were recorded, the level of harm was frequently downplayed. Staff described a culture in which catastrophic outcomes, including stillbirths and life-changing maternal injuries, were routinely classified as low or no harm. A case of a 4th degree tear requiring a stoma was graded as low harm; a term stillbirth linked to mismanaged hypertension was recorded as no harm [Clinical Governance, p. 277 (upper)]. This misclassification was not accidental. It was a pattern that removed the trigger for a full Serious Incident investigation and, critically, switched off the statutory Duty of Candour.

The concept of “avoidability” was widely misused. Under national guidance, incidents should be reported and graded based on the outcome experienced, not on whether the care was considered substandard. At NUH, the opposite logic took hold. If an outcome was deemed unavoidable, the incident often wasn’t reported at all. One member of the governance team told the Review: “Massive emphasis on ‘avoidability’ – anything deemed ‘unavoidable’ was not investigated” [Clinical Governance, p. 277 (lower)]. This approach buried harm and shut down learning before it could begin.

Serious Incidents Buried as Minor Matters

Even when staff inside the maternity service tried to escalate serious cases, they frequently hit a wall. The Trust’s Incident Review Panel, chaired by a senior manager, became a choke point. Staff described repeated attempts to have cases declared as Serious Incidents being rejected. One senior clinician raised the same concern on four separate occasions, including the case of baby Wynter Andrews, and was told each time it did not meet the threshold [Clinical Governance, p. 283 (mid)]. A midwife recalled presenting a case alone and being repeatedly told, “Do a local investigation… all the time” [Clinical Governance, p. 283 (lower)].

The panel was described as intimidating and male-dominated, and the voices of midwives and nurses carried less weight than those of consultants. Some staff reported that decisions to downgrade or close cases were effectively made before the meetings took place. The use of High Level Investigations – a local process intended for less serious incidents – became a way to avoid external reporting. A 2017 retrospective review found twelve cases that should have been declared as Serious Incidents but had not been. The pattern persisted for years [Clinical Governance, p. 273 (upper)].

Investigations That Looked Without Seeing

When investigations were carried out, they were too often weak, slow, and designed to avoid uncomfortable truths. Root Cause Analyses were descriptive rather than analytical. They focused on individual actions instead of systemic failures. Contributory factors were overlooked, and recommendations were vague or administrative. One internal report from 2017 noted that investigations were inconsistent, harm was understated, and there was no evidence of thematic review. It concluded that learning was not embedded [Clinical Governance, p. 272 (mid)].

Staff described investigations being rushed and treated as a tick-box exercise. Obstetric consultants dominated the process, and midwives felt excluded or bullied. One governance midwife told the Review that at rapid review meetings, consultants “would decide whether to proceed – generally they would close things down at that stage” [Clinical Governance, p. 283 (lower)]. Another described governance meetings as “brutal,” with reports “ripped to shreds” after hours of preparation [Clinical Governance, p. 286 (mid)].

The result was that investigations rarely got to the root of what went wrong. Action plans were produced, but they were often not implemented or followed up. Staff across the service described a cycle in which the same issues – communication failures, poor escalation, inadequate fetal monitoring – were identified in incident after incident, year after year, without meaningful change. One member of staff summarised the experience: “It felt like no one ever learned anything” [Staff Voices, p. 115 (upper)].

Families Left in the Dark

When the governance machine failed to investigate, families were the ones left without answers. The Review heard repeatedly from parents who were told that lessons would be learned, only to discover later that no investigation had taken place, or that the findings had been altered, or that they had been excluded from the process entirely. The Hawkins family endured almost a decade of what the report calls “obfuscation, delay, callousness and incompetence” before an external review finally confirmed that their daughter’s death was avoidable [Executive Summary, point 9].

The statutory Duty of Candour was routinely ignored. Incidents that should have triggered a full and honest explanation to the family were graded too low or never reported, breaking the legal obligation to be open. In one case, a woman who suffered a ruptured uterus and an 8.7‑litre haemorrhage was managed through a local multidisciplinary review and told it did not meet the criteria for a Serious Incident investigation. Her family never received a full, independent account of what had happened [Clinical Governance, p. 289 (lower)].

Even when debrief meetings did take place, they were frequently delayed, poorly conducted, or lacked compassion. Some parents waited months. Others were told to attend appointments only to find the clinician was unavailable. Written letters following debriefs were often cold, medicalised, and, on occasion, appeared to blame the mother. One letter following a termination for fetal abnormality attributed responsibility to the mother in a way that caused deep distress [Postnatal Care, p. 223 (upper)].

The Same Mistakes, Again and Again

The clearest evidence that governance failed is that the same problems recurred across more than a decade. Six external reviews of maternity services, commissioned by the Trust itself between 2015 and 2022, all identified the same deep weaknesses: poor culture, bullying, under‑resourcing, dysfunctional governance [Corporate Culture, Governance & Leadership, p. 262 (lower)]. Each time, the Board was told that actions were being taken. Each time, the underlying system did not change.

The Review Team examined a series of thematic reviews conducted after the COVID‑19 pandemic, intended to clear a backlog of unclosed incidents. These reviews found consistent under‑reporting, inconsistent harm grading, and weak investigations. They also concluded that learning was not led or shared. But the reviews themselves did not revisit the individual cases. They did not re‑grade the harm. Families were not given feedback. One review acknowledged that only 8% of neonatal incidents were classified as moderate harm and noted this was “difficult to reconcile” with the nature of the cases. It recommended no further action [Clinical Governance, p. 293 (upper)].

Nottingham was not learning. It was documenting its own failures and then filing them away.

Recent Reforms and Remaining Risks

Since 2022, there has been a genuine effort to break this cycle. The governance team has been restructured and brought into line with the Trust’s corporate processes. Investigation backlogs are being cleared. Staff speak of a more open culture and greater willingness to involve families [Clinical Governance, p. 291 (mid), p. 292 (upper)].

However, the shift to the new Patient Safety Incident Response Framework (PSIRF) has been difficult. The framework requires a sophisticated, systems‑based approach and greater family engagement. NUH has struggled with implementation. The number of formal Patient Safety Incident Investigations remains low. Staff report that After Action Reviews and swarm huddles are not yet embedded, and training is incomplete. Most concerningly, some incidents that would reasonably warrant a full investigation under PSIRF are still being managed through less rigorous local reviews [Clinical Governance, p. 289 (lower)].

The risk remains that, under the cover of a new framework, the old habits of downgrade and avoidance could return. The test of whether governance at Nottingham has truly changed will not be found in policy documents, but in whether the next avoidable harm triggers a rigorous, honest, and compassionate response – or whether the door is quietly closed once again.

Where the Cracks Opened – Clinical Consequences

The failures in leadership, staffing, culture, and governance described in previous sections were not abstract. They were the conditions in which clinical harm became inevitable. This section traces how those system-wide weaknesses manifested in day-to-day care, with real and sometimes fatal consequences.

The Triage Gatehouse

Maternity triage at Nottingham University Hospitals was supposed to be a safety net. Instead, it functioned as a barrier. Women who phoned with concerns were repeatedly told to stay at home. The unit’s own guidance, that women should be invited in after calling three times, was twisted into a requirement: women had to call three times before being allowed to come in [Signature Case, p. 47 (lower)].

Staff described a culture of gatekeeping. Women in early labour were “the least prioritised,” and there was “pressure to make women in the latent phase normal” [Signature Case, pp. 48–49 (upper)]. One midwife recalled being told to “coerce them into going home” [Signature Case, p. 54 (mid)].

The consequences were severe. In the Signature Case of Harriet Hawkins, Sarah made repeated calls with increasingly painful contractions. She was told she was “not in labour” and to remain at home. When she was finally admitted, she was 9 cm dilated. Harriet’s heartbeat could not be found. The Review Team later identified nine missed opportunities in care, each of which would most likely have prevented her death [Signature Case, p. 39 (lower)].

This pattern recurred across the review period. A mother in 2014 called three times with pain and bleeding, was told to “calm down,” and arrived to find her cervix nearly fully dilated. Her baby suffered hypoxic‑ischaemic encephalopathy [Intrapartum Care, pp. 155–156 (lower)]. In 202a high‑risk mother was told over the phone that she could not be in labour because she was able to hold a conversation. She arrived to find herself 6 cm dilated and her baby in a poor condition [Intrapartum Care, p. 155 (mid)].

Ignoring the Labouring Woman

Even when women were admitted, their concerns were often dismissed. Fetal heart abnormalities were not recognised. CTG traces were misclassified as normal when they were suspicious or pathological. Oxytocin was continued, and sometimes increased, in the presence of hyperstimulation, despite clear evidence of fetal distress [Intrapartum Care, pp. 148–149 (mid), pp. 158–160].

In 2019, a mother in established labour at 34+1 weeks was started on oxytocin without a clear indication. The CTG was abnormal, yet the infusion continued. Progress was slow, and a plan for forceps in theatre was delayed due to unit activity. The baby underwent cooling and was diagnosed with hypoxic‑ischaemic encephalopathy [Intrapartum Care, p. 152 (mid)].

Across more than a decade, failures to escalate or to involve senior staff were a common theme. The labour‑ward coordinator’s oversight was often absent or undocumented. Junior midwives were left with complex cases and felt unable to call for help. A staff member recalled, “On shift when a major incident happened, coordinators were toxic” [Intrapartum Care, p. 151 (lower)].

The Consequences of Under‑Staffing on the Wards

On the postnatal wards, chronic under‑staffing meant that basic safety checks were missed. Women with rising blood pressure were not reviewed. Thromboprophylaxis was not prescribed, or doses were omitted. In several cases, mothers developed pulmonary emboli as a direct result [Postnatal Care, pp. 203–204 (lower)].

Babies were not weighed, and feeding difficulties were not escalated. The telephone triage model that persisted long after the pandemic meant that jaundiced, dehydrated babies were not seen face‑to‑face. One baby, described as pale with nearly 20 per cent weight loss, was followed up by telephone. On admission, the baby had an unrecordable temperature and significant metabolic acidosis [Postnatal Care, pp. 217–218 (mid); Clinical Governance, p. 280 (lower)].

Maternity‑support workers carried out community visits without clear escalation pathways or standard operating procedures. Concerns noted on one visit were not passed on or acted upon, and in several instances babies required emergency admission days later [Postnatal Care, pp. 216–217].

The Deadly Delay in Recognising Haemorrhage

Postpartum haemorrhage (PPH) was a recurring area of concern. The Review found multiple cases where blood loss was underestimated, major‑obstetric‑haemorrhage protocols were activated late or not at all, and women were not transferred to theatre until they were already in shock.

In 2016, a mother’s blood loss after birth was estimated visually rather than measured. Observations were not carried out in a timely way, and she was not escalated until near collapse. Her total blood loss was 3.5 litres [Intrapartum Care, pp. 162–163 (lower)]. In another case in 2019, the emergency buzzer was not pulled, no cannula was in place, and the major‑haemorrhage protocol was not activated until transfer to theatre. Blood loss reached 4.9 litres. The mother later said she believed she was going to die [Intrapartum Care, p. 165 (upper)]. She was right; she was going to die.

A Pattern Repeated Across the Service

These clinical events did not occur in random isolation. They were the direct product of the system described throughout this report: triage services that were gatekeepers rather than safety nets; labour wards where staff were too few and too fearful to escalate; postnatal wards so stripped of resource that basic monitoring was impossible; and a governance system that failed to identify or learn from any of it. As the next section will explore, there are now early signs of change, but the legacy of these failures is measured in lives lost and lives permanently altered.

Conclusion

The maternity services at Nottingham University Hospitals did not fail because of a few isolated mistakes. They failed because the systems meant to keep women and babies safe were broken at every level. For over a decade, warning signs were ignored or buried. Governance processes that should have detected harm instead concealed it. A culture of bullying and fear stopped staff from speaking up. Chronic under‑staffing became normalised, and leaders at every level chose reassurance over honest scrutiny.

These failures were not separate problems; they fed one another. A board that did not ask difficult questions allowed a dysfunctional maternity leadership to persist unchecked. That leadership, unstable and often invisible, failed to address the toxic behaviours that silenced front line staff. Exhausted and unsupported midwives and doctors then worked in an environment where basic safety checks were missed, escalation was delayed, and women’s concerns were dismissed. The result was a cascade of avoidable harm, from missed fetal distress to catastrophic postpartum haemorrhages, from stillbirths to life‑changing maternal injuries.

The Ockenden Report is clear that these conditions did not emerge overnight [Executive Summary, point 8]. Multiple external reviews between 2015 and 2022 said the same things: the culture was toxic, governance was weak, and leadership was absent [Corporate Culture, Governance & Leadership, p. 262]. Each time, the board was assured that things would improve. Each time, they did not. The consequences are measured in the lives of babies like Harriet Hawkins and Wynter Andrews, and in the trauma carried by hundreds of families who were let down not only by their clinical care, but by the defensive and dishonest responses that followed.

There are now signs of change. Recent inspections and staff voices point to more visible leadership, better governance, and a genuine commitment to listen to families [Clinical Leadership, p. 300–301; Clinical Governance, p. 291]. But these improvements are recent and fragile. The deepest failures – the cultural norms that allowed poor behaviour to flourish, the chronic under‑resourcing, the instinct to protect reputation over patients – took years to embed and will take years to undo.

Nottingham’s story is a warning. It shows that maternity safety cannot be assured by policies and protocols alone. It depends on leaders who listen, staff who feel safe to speak, and governance that seeks the truth rather than reassurance. It depends on treating every woman’s concern as a signal, not a nuisance. Until those conditions are met across the NHS, the lessons of this report will remain unlearned, and families will continue to pay the price.