The largest maternity inquiry ever undertaken in the UK, investigating the care of approximately 2,500 families at Nottingham University Hospitals NHS Trust (NUH), is published this week. Led by senior midwife Donna Ockenden, the review examines stillbirths, neonatal deaths, maternal deaths and severe injuries to mothers and babies at the Queen’s Medical Centre (QMC) and Nottingham City Hospital between 2012 and 2025. It marks the culmination of a decade-long campaign by families who have fought for answers and fundamental change.
An investigation of unprecedented scale
The Ockenden review, which began in May 2022, is the largest of its kind in British history, with around 2,505 individual cases scrutinised. The inquiry was prompted by repeated failures and a growing body of evidence that systematic problems at NUH had led to preventable harm on a devastating scale. Families have described feeling dismissed, gaslit and subjected to a culture of cover‑ups, and the report is expected to lay bare the depth of the crisis.
Family stories of preventable tragedy
Among the cases examined is that of Wynter Andrews, who died at QMC in 2019 from hypoxic ischaemic encephalopathy – a loss of oxygen to the brain that could have been prevented had staff delivered her earlier. Her mother, Sarah Andrews, said she was told to stay at home for six days while in labour. “I didn’t feel like I had any other choice,” she said. When she finally reached hospital, “the care was just beset by failures”. Staff attempted resuscitation for 23 minutes while she and her husband watched. “One said to us: ‘If we listen to every mother’s concerns, we’d be overrun,’” she recalled. A coroner later ruled the death a “clear and obvious case of neglect”. NUH was fined £800,000 in 2023 after admitting failures in Wynter’s care, and in February 2025 the trust was fined a further £1.6 million for failings linked to the deaths of three babies, including Wynter, after pleading guilty to charges of failing to provide safe care and treatment.
Felicity Benyon was 29 when she underwent an emergency hysterectomy at QMC after giving birth in 2015. Medics accidentally removed her bladder, leaving her with a urostomy bag. She was initially told the placenta accreta had “completely enveloped” the bladder, but a subsequent investigation found the bladder was healthy and had been removed unnecessarily. “I was absolutely floored,” she said. “It should have just been a hysterectomy and then home, instead of living with lifelong complications.” NUH later admitted liability and issued an unreserved apology. Felicity said the experience had destroyed her trust in doctors. “I don’t feel safe in hospitals – but that’s the place you’re supposed to feel safe because it’s where you’re at your most vulnerable.”
Caitlin Stringer was born prematurely in 2021 at Nottingham City Hospital. At 30 days old she developed necrotising enterocolitis (NEC), a life‑threatening gastrointestinal emergency. Her parents allege staff failed to treat her quickly, leading to a collapse and severe brain injury. Emily Stringer, Caitlin’s mother, said they had raised concerns for days about her abdomen swelling and lethargy, but “staff had an answer for everything. No one was either able or willing to join the big picture together.” An external review commissioned by the trust found that an X‑ray taken 15 hours before Caitlin collapsed had diagnosed NEC, and that she should have been given antibiotics within an hour – but was not. Caitlin is now expected to die in childhood. She has cerebral palsy and suffered multiple respiratory arrests last year. “We know that one day one of these will be fatal,” her mother said.
Quinn Parker died at Nottingham City Hospital just 36 hours after his birth in 2021. His mother, Emmie Studencki, attended hospital four times with bleeding in late pregnancy and says her requests for a caesarean section were ignored. His father, Ryan Parker, said they had “a feeling that something wasn’t right – what is really happening is Quinn is just slowly dying but no one’s doing anything.” Paramedics had noted concerns about a rigid abdomen and blood loss of over a litre, but the notes were not properly collected by the hospital. An inquest concluded that an earlier delivery might have saved Quinn’s life. The coroner also highlighted that dissection of Quinn’s placenta by pathology staff had compromised the investigation – a recurring problem in similar neonatal deaths at NUH. The trust was fined £1.6 million in February 2025 for failings in the deaths of Quinn, Adele O’Sullivan and Kahlani Rawson.
Harriet Hawkins was stillborn at Nottingham City Hospital in April 2016 after her mother had been in labour for six days. An external review identified 13 failures and concluded the death was “almost certainly preventable”. Her mother, Sarah Hawkins, said the trust initially blamed infection and took 159 days to log the death as a serious incident. “It just felt like a complete cover‑up,” she said. Between April 2014 and February 2017 there were 35 stillbirths at the trust with no Serious Untoward Incident investigations opened. The family received a £2.8 million settlement in 2021, believed to be the largest payout for a stillbirth clinical negligence claim, partly due to psychiatric injury worsened by the trust’s lack of transparency. The Care Quality Commission is now conducting an external review into its own handling of Harriet’s case, after her parents claimed the regulator was not made aware of it for years – a claim the CQC disputes.
Systemic failures, toxic culture and discrimination
The Ockenden report is expected to detail widespread systemic failings that go far beyond individual errors. Investigations have repeatedly identified a “toxic culture” at NUH’s maternity units, including poor teamwork, inadequate staffing and a failure to listen to both frontline staff and families. One former senior midwife reported a “culture of fear” in which staffing concerns were routinely ignored. Between 2010 and 2020, the trust was accused of “failure or delay to treatment” in 25 incidents and “failure to recognise complications” on 13 occasions.
The inquiry is also expected to reveal instances of racism and discrimination towards mothers. A review lead has highlighted the “impact of discrimination against women of colour, working class women, women with mental health challenges, and younger parents leading to poorer outcomes”. NUH has stated it does not tolerate discrimination and is working to address such behaviour.
Record‑keeping was found to be poor, and deaths were not always referred to the coroner as required. The Care Quality Commission rated NUH’s maternity services “inadequate” in October 2020 and issued a warning notice. Despite some improvements, both QMC and Nottingham City Hospital’s maternity services remain rated “requires improvement”. The trust has been prosecuted multiple times by the CQC for safety breaches, including the February 2025 fine.
Separately, Nottinghamshire Police’s Operation Perth is examining the care provided to at least 200 families and is considering corporate manslaughter charges. A national review of maternity and neonatal infrastructure has also pointed to poor building conditions – including ventilation, space and inadequate adjacencies to theatres – as contributing to service failures at NUH.
Trust response and families’ call for wider change
Anthony May, who became NUH’s chief executive in September 2022, said: “I want to pay tribute to the bravery of the many families who have worked tirelessly to get answers and to make maternity services safer for others. I have met some of the affected families, and they have shared their painful and life‑changing experiences with me, for which I am very grateful. I am very sorry for the pain and suffering these families have endured.” He said NUH staff had “shown their commitment to change” and that upon receiving the review’s findings, the trust would “consider carefully what we need to do next to ensure that we learn from what happened in the past and to continue to improve maternity services.” The trust has implemented increased staffing and investment in training, and is working on a “People First Strategy” to reshape services. The Nottingham Maternity Families Group, however, has renewed its call for a statutory public inquiry into maternity care across England, warning that other trusts may already be “Nottinghams” waiting to be exposed.
