Last night’s BBC Panorama programme examining maternity care at Nottingham University Hospitals NHS Trust was difficult but important viewing. The experiences shared by families, alongside accounts from former staff members, painted a deeply concerning picture of a maternity service where opportunities to listen, escalate concerns and intervene safely were repeatedly missed.
The allegations featured in the programme were stark. Families described concerns during labour and pregnancy allegedly being dismissed, delays in intervention, failures to recognise deterioration and a culture in which some women felt unheard and unsupported at the most vulnerable point in their lives. Former staff members also spoke about workforce pressures, understaffing and cultural issues within the service.
At the centre of this remains the ongoing independent review led by Donna Ockenden, which is now understood to involve around 2,500 families and represents the largest maternity inquiry in NHS history. The final report is due to be published later this month.
In the programme, Donna Ockenden observed: “There have been many families who have not been told the truth. They have been told for years by the Trust: that was just bad luck, it was only you.”
Usually serious incidents are reported to regulators who can then scrutinise them. However, Nottingham University Hospitals NHS Trust devised its own classification system, which meant that many serious incidents were not reported and so avoided scrutiny. Last year, the Trust was fined a record £1.6 million for 3 cases involving placental-abruption, which is a serious complication where the placenta partially or completely separates from the uterus wall and puts mum and baby at risk. It was the second time the Trust had been prosecuted for failing to keep mothers and babies safe.
According to MBRRACE there has been a 20% increase in maternal deaths over the past 15 years. The mortality rate for pregnant black women is almost 3 times higher than for white women. The Nottingham review is the first maternity inquiry centred on a large, multi-ethnic population. The experiences of Black and Asian families, who have long had worse maternity outcomes due to racism and disciminatory care, will be a key focus of the review.
For many families affected by avoidable maternity harm, Panorama will have been another painful reminder of the experiences they have lived through for years. However, public scrutiny also matters. It ensures that these issues remain firmly in focus and reinforces the importance of transparency, accountability and learning within maternity services.
Sadly, the concerns emerging from Nottingham are not isolated. The themes being reported mirror many of the findings identified within the earlier Ockenden Review into maternity services at Shrewsbury and Telford. That review identified repeated failures to investigate and report incidents properly, failures to learn from previous mistakes, inadequate foetal monitoring, delays in escalation and insufficient consultant involvement in high-risk care.
What is particularly troubling is the extent to which similar themes continue to emerge across different Trusts nationally. Time and again, investigations into maternity care identify recurring issues including poor communication, failures to listen to mothers and families, inadequate staffing, cultural defensiveness, and delays in recognising foetal or maternal distress.
Whilst individual clinical errors are often a factor in cases of avoidable harm, maternity safety is ultimately a much wider systemic issue. Safe maternity care depends upon properly resourced services, effective multidisciplinary working, robust escalation processes and a culture where concerns raised by both staff and patients are taken seriously.
There is also an important human reality behind every statistic and every investigation. Families affected by maternity negligence often face lifelong consequences, including the loss of a baby, serious maternal injury or catastrophic neurological injury to a child. The emotional, psychological and financial impact can be profound and enduring.
The publication of the Nottingham Ockenden Review later this month is therefore likely to be a watershed moment for maternity services nationally. Families will rightly hope that it does more than simply catalogue failings. The real test will be whether its findings lead to meaningful change and sustained investment in maternity services across the NHS.
Ultimately, maternity safety cannot become an issue that only receives attention following tragedy or public inquiry. The lessons identified repeatedly across these investigations must finally translate into lasting change if future families are to be protected from avoidable harm.
Quote from author Hannah Carr, Legal Director and Specialist Medical Negligence Solicitor from MDS, said “The Nottingham Review is now the 4th major inquiry into maternity services in the NHS since 2013. Despite hundreds of recommendations aimed at improving maternity safety, many of the same failings continue to emerge. Further reviews have now been commissioned in Leeds and Sussex, and the report of the Baroness Amos National Maternity & Neonatal Investigation is also awaited.
For the families affected, this is about far more than statistics or reports. Being told that your baby’s death was unavoidable is devastating beyond words, but to later discover that it may not have been unavoidable at all is unimaginable. What should have been a life filled with hope, plans and memories instead becomes a life of endless ‘what ifs’.
The recurring themes across these investigations demonstrate why maternity safety must remain a national priority and why meaningful cultural and systemic change across NHS maternity services is now urgently required.”
