Background
The Review into maternity services at Nottingham University Hospitals NHS Trust (NUH) was commissioned following serious and longstanding concerns about the safety and quality of care provided to mothers and babies at the Trust’s two main sites: Queen’s Medical Centre and Nottingham City Hospital.
Concerns were raised over many years by bereaved families and regulators, including the Care Quality Commission (CQC), highlighted deficiencies in the maternity services provided at NUH.
In response, NHS England established a nationally commissioned independent review in May 2022, replacing a smaller regional inquiry after families called for a more robust investigation.
The review is chaired by Donna Ockenden, the senior midwife who led the landmark review into maternity failings at The Shrewsbury and Telford Hospital NHS Trust.
Since it started, the Nottingham review has become the largest maternity inquiry in NHS history and is thought to involve 2,500 families. The cases being considered involve stillbirth, neonatal death, maternal harm and death, and brain injury.
Purpose of the Review
The key objectives of the Ockenden Review are:
- To listen to women and families and fully understand their experiences of care.
- To investigate cases of serious concern, including deaths and injuries.
- To identify systemic failings within maternity services.
- To provide recommendations to improve safety, quality, and equity of care.
- To ensure learning is shared early, enabling immediate improvements within services.
The review specifically examines how concerns raised by families and staff were handled, with the goal of ensuring greater transparency, accountability, and patient safety in the future.
Key Developments During the Review
Since its launch, the review has evolved significantly:
- The number of cases under investigation expanded dramatically, eventually reaching around 2,000–2,500 families, reflecting the scale of concern about the NUH maternity services.
- The review broadened to include cases dating back as far as 2006 for maternal deaths; however, most cases are from 2012 onwards.
- An “opt-out” approach was adopted in 2023, rather than the traditional “opt-in” approach. This increased participation and ensured more families were included.
- Nottinghamshire Police announced in 2023 that it was opening an investigation, which would run alongside the review to examine potential criminal matters.
- The review has provided ongoing feedback to the Trust, enabling immediate changes such as staffing improvements and safer practices.
Timeline of the Nottingham Ockenden Review
Pre-Review Context
- 2006–2021 – Period covering many of the cases later investigated, including maternal deaths, stillbirths, and neonatal harm.
Establishment and Launch
- May 2022 – Donna Ockenden appointed to lead the independent review.
- June 2022 – Preparatory work and early engagement with families begins.
- 1 September 2022 – Review formally begins.
Expansion and Engagement
- 2023 (early) – Hundreds of families join the review; initial participation lower than expected.
- July 2023 – NHS England introduces an opt-out approach to increase inclusion.
- September 2023 – Police announce plans to investigate maternity services alongside the review.
Ongoing Investigation and Learning
- 2024 – Continued evidence gathering from families and staff; regular feedback leads to ongoing service improvements.
- May 2025 – Review closes to new cases after significant expansion.
Reporting Phase
- February 2025 – Publication (planned for September 2025) delayed due to increased number of cases and scope.
- September 2025 (planned) – Original target date for publication of findings.
- June 2026 (expected) – Final report due, setting out findings and recommendations.
Conclusion
The Nottingham Ockenden Review is a major investigation into maternity safety, which would not have started if not for the determination and persistence of families who have been affected by poor maternity care at NUH.
The aim of the Review is not only to establish what went wrong but also to make recommendations for change that ensure lasting improvements in maternity care across the NHS. The problems in Nottingham are not isolated. After the Nottingham Review concludes, Donna Ockenden will start a review into maternity care in Leeds. Another review has been commissioned in Sussex, and the report of the National Maternity & Neonatal Investigation chaired by Baroness Amos is also due to be published soon.
The scale, depth, and expected findings of the Nottingham Ockenden Review will be shocking, but for many will not be surprising. We hope that it leads to us seeing real measurable change at NUH and across the country.
Quote from author. Navdeep Kainth, Partner and Specialist Medical Negligence Solicitor from MDS, said “The publication of the Ockenden Review is an important step for the many families affected by failures in Nottingham's maternity services. The report will provide an important opportunity to acknowledge the experiences of those who suffered avoidable harm to ensure that their voices remain at the centre of efforts to improve patient safety. It is vital that lessons are learned and meaningful changes are made to improve patient safety.”
