Summary

  • This page contains details that some may find distressing

  • Hundreds of babies and mothers died or were harmed due to "deep-rooted, systemic failures" in maternity care, an independent review into services run by Nottingham University Hospitals NHS Trust finds

  • The review, the largest in NHS history, also finds a "bullying, toxic culture" and "persistent failure to listen to mothers and fathers"

  • Dr Jack Hawkins, whose daughter Harriet was stillborn in 2016, says the "relentless" 10-year campaign has ended with "profound sadness" and a "deep sense of anger"

  • "Babies were treated with an absence of dignity and the hospital frequently failed to keep our loved ones safe," he adds

  • Gary Andrews, whose daughter Wynter died 23 minutes after she was born in 2019, says "it shouldn't have taken families all this time to be heard"

  • Review chair Donna Ockenden calls for "immediate and essential actions across England"

  • Health Secretary James Murray describes the findings as "chilling" and vows to take "immediate steps"

  • The trust's top executives "apologise unreservedly" - read their open letter in full

Media caption,
Mothers told they 'were not important' and to 'pull themselves together'
  1. 'Wynter would still be here'published at 14:22 BST

    Addressing the trust directly, Gary Andrews - whose daughter Wynter died 23 minutes after being born in 2019 - said: "If you'd listened to concerns, there would be hundreds of babies still alive.

    "Wynter would still be here - and her brother would not be looking at a gravestone."

    In 2023 NUH were fined £800,000 after admitting failings in Wynter's care. At the time it was the largest handed out to an NHS trust over maternity care.

    Sarah and Gary AndrewsImage source, PA Media
  2. 'No options off table' after statutory public inquiry callspublished at 14:18 BST

    On the question of a statutory public inquiry - which would compel witnesses to give evidence and something the families have called for today - Health Secretary James Murray said: "I just want to be clear, no options are off the table."

  3. Good staff 'were also victims'published at 14:17 BST

    Emily Stringer - whose daughter Caitlyn suffered serious injuries - said the families "recognise there were good staff" who were working in a "bad environment".

    "They were also victims," she said.

    "Only accountability can incentivise that culture change in maternity services."

  4. Mother of stillborn baby calls cover-up 'horrific'published at 14:16 BST

    Families at the press conference in Nottingham are now answering questions from the media.

    Sarah Hawkins - bereaved parent of daughter Harriet and a whistleblower of the maternity scandal, alongside Dr Jack Hawkins - said she felt let down by those who cared for her.

    Sarah was a senior physiotherapist and Jack was a consultant doctor.

    She said: "We dedicated our careers to the NHS - I thought I would trust my colleagues - I was low risk. Then to be treated during my six-day labour like I was, I couldn't compute it.

    "After Harriet died - the cover-up was horrific, we knew this because we knew the system."

    Asked what accountability looks like moving forward, Jack added those who cared for Sarah and Harriet should be "brought before the courts".

    Sarah HawkinsImage source, BBC/Chris Waring
  5. Disrespect and humanity left health secretary 'aghast'published at 14:09 BST

    Warning: This post contains details that some may find distressing

    Murray has also detailed the way in which the bodies of dead babies were wrongly handled by NUH.

    His voice faltered as he said failures at maternity services showed there was a "level of disrespect and lack of humanity that, I’ll be honest, left me aghast".

    He said babies were referred to as a "specimen or sample", that a baby was placed in a mortuary space which was already occupied by an "unknown and unrelated adult", a baby disposed of as clinical waste against the wishes of their parents, and another baby's body kept in a domestic fridge in a bereavement room.

    He told MPs: "The emotional and psychological effect of these dehumanising failures was to lay out the most profound disrespect on the most unbearable distress. There is also evidence that the trust actively decided not to report failings in mortuary care to families."

    He said he had asked NHS England to write to trusts to ensure failings were not repeated elsewhere.

    He added the Human Tissue Authority would require all mortuaries to review internal records over the last decade to ensure all incidents had been logged and reported. Staff will have to report back by 16 October.

  6. 'On behalf of the NHS, I am sorry'published at 14:04 BST

    Continuing to address the House of Commons, Health Secretary James Murray apologised to the families affected.

    He said: "To all of those who have suffered so appallingly, I say today on behalf of the NHS, I am sorry.

    "I am sorry, not just for the failures or the heartless and undignified treatment, but also because your cries of concern went unheard for too long.

    "And so the government will act. We will act by taking immediate steps, including to expand Martha's Rule to all maternity in neonatal settings, so that parents can demand a second opinion if they feel their concerns are being ignored."

    James MurrayImage source, Peter Byrne/PA Wire
  7. Health secretary 'felt numb' after meeting Nottingham familiespublished at 14:02 BST

    Health Secretary James Murray told the Commons he met families taking part in the maternity review last week.

    He said: "I felt numb after hearing the depth of their pain. I felt even more numb when I considered how many families not in the room went through such a trauma too, and the forgotten children who survived but lived with the consequences of failings in maternity care every day.

    "I felt devastated that so many women and babies, as well as their fathers and other family members, had suffered injury, death and lasting trauma whilst under the care of the NHS.

    "Now, having met the families and having seen the report, I feel appalled by the neglect, incompetence, racism, discrimination, contempt and harassment that so many suffered.

    "I feel heartbroken to know that at so many times, when they tried to raise the alarm about their care, they were ignored, sneered at, disbelieved, blamed and lied to."

  8. Health secretary tells Commons review findings are 'chilling'published at 13:53 BST

    Meanwhile, Health Secretary James Murray has starting addressing the findings of Ockenden's review in the House of Commons.

    He described the revelations as "chilling".

    Murray said: "Donna Ockenden’s review is the largest ever into a maternity service in the history of the NHS.

    "The nature and sheer scale of the failings it exposes are horrific. It uncovers dangerously and tragically deficient care at almost every turn."

    Our political editor Pete Saull, who has been watching Murray's address, said several MPs were visibly moved as he delivered his statement.

  9. Families call for a statutory public inquirypublished at 13:52 BST

    Addressing the press conference, Jack added: "The time has come for there to be a statutory public inquiry across England.

    "Every family affected deserves the truth and accountability."

    Jack Hawkins
  10. 'Questions must be asked' after some senior leaders refused to take part in reviewpublished at 13:50 BST

    We heard earlier that some senior leaders had refused to take part in Ockenden's review, leading the government to announce a raft of measures to boost accountability - including ensuring that NHS staff who refuse to engage in future reviews are compelled to do so, or face up to two years in prison.

    Jack said: "The fact significant senior staff chose not to take part in this review is appalling - to them maternity safety does not matter, but their reputation does.

    "Questions must be asked whether these people are fit to continue to work in the NHS."

  11. NUH staff should be properly supported in jobs, families saypublished at 13:48 BST

    Jack has told the press conference that families were "horrified" by what staff members at NUH shared with the review, and that they should be "properly supported" in their jobs.

  12. Recommendations 'must be treated with the utmost seriousness'published at 13:47 BST

    Jack said the actions for learning identified in Ockenden's review "must be treated with the utmost seriousness".

    He added: "Anything less would be a betrayal of the families."

  13. 'We were not told the truth, even after death'published at 13:44 BST

    Jack added: "Some of the themes identified are ones that we had direct and personal experience of - our concerns were dismissed and not acted upon - we were not told the truth, even after death.

    "The hospital frequently failed to keep our loved ones safe."

  14. 'Profound sadness and deep sense of anger'published at 13:43 BST

    Dr Jack Hawkins - whose daughter Harriet was stillborn in 2016 - is speaking at the press conference.

    He said: "The relentless, and at times, unbearable 10-year campaign, has resulted in the profound sadness and deep sense of anger that we learn of the full extent of the scandal at NUH."

    press conference
  15. Families to give their reactionpublished at 13:37 BST

    A press conference is due to start shortly where we will hear reaction from bereaved families who shared their stories with the inquiry.

    We will bring you the latest lines as soon as things get under way.

  16. Ockenden 'will make sure changes happen', says bereaved fatherpublished at 13:17 BST

    Wynter Andrews died 23 minutes after she was born in 2019.

    Her father Gary was listening to Donna Ockenden’s speech this afternoon.

    He told BBC Radio Nottingham: “This can't be ignored now, it is too important. It shouldn't have taken families all this time to be heard.

    “You’ve got a situation where senior leaders are so concerned about reputational management that they don’t want families to understand the harm they received.

    “We were told it was just one of those things, and yet in the weeks that followed I found an article about Harriet Hawkins and it was almost a copy and paste job of what happened to Wynter.

    “We need action. We need change.

    “I felt like Donna was this Mary Poppins character who one day has to leave, but she’s sticking around for a bit longer to make sure that these changes happen.”

  17. Affected families to be offered meetings, Ockenden sayspublished at 12:58 BST

    Donna Ockenden told the BBC she hopes the process of "family feedback" will provide families with "the answers they have waited for so long".

    Families are expected to receive their feedback by the end of 2026 at the latest.

    Each family in the maternity review is assigned a case number. The lower the number, the sooner they will receive their feedback, as the numbers reflect the order in which cases were added to the review.

    "I suspect the vast majority of families will receive their report and won't have further questions. However, there are various options depending on the family's needs and how serious, or not, our findings are," Ockenden said.

    "I have said that where mothers have died, even where the care is appropriate, we will offer an opportunity for face-to-face meetings in Nottingham. In addition, for all families where we find major concerns, they will be offered the opportunity, if they want it, for face-to-face meetings.

    "We will also offer virtual meetings and telephone conversations - no-one is on their own on receipt of their family feedback."

    Donna Ockenden
  18. Women in labour told to 'pull themselves together'published at 12:50 BST

    Ockenden said women’s consent was not sought during labour and some interaction from staff was at times "cruel".

    Women in the middle of labour were told to "pull themselves together" while another submission from a mother recalled how she was told to “wait their turn” as there was “other women they had to sort.”

    Ockenden said her team found examples of what she described as the "normalisation of deviance" and there were significant concerns raised as there should have been medical interventions but natural birth continued.

    She added: "These were not isolated incidents… this was a pattern that caused long-term harm.

    "Some of those babies are no longer here or suffered serious harm."

  19. Review also sets out 'local actions' for NUHpublished at 12:44 BST

    Ockenden's report also outlines a set of local actions for learning (LAFLs) for NUH.

    The LAFLs directly address the failures identified by the review team and are specific actions for the trust to take.

    These include:

    • Urgent improvements to risk management and monitoring
    • Strengthening escalation protocols, communication and safe transport of care
    • Improving neonatal safety and care
    • Standardising emergency care and reducing variation in practice
    • Governance, leadership and accountability
    • Treatment of families during investigations in care
    • Improving psychological support for families and staff
    • Improving communication, administration and implementation of change
    • Improving post-death care and bereavement processes
    Donna Ockenden, wearing purple, holds up a copy of her report
  20. Report details serious post-death care incidentspublished at 12:42 BST

    Warning: This post contains details that some may find distressing

    We heard Donna Ockenden discuss post-death care at NUH, including a "very serious incident" in 2022 involving the release of the wrong baby to a funeral director.

    In the report, one instance in 2019 was also highlighted, when "one very early gestation baby was inadvertently disposed as clinical waste by laboratory staff after her post-mortem examination, resulting in a complete loss of dignity for the baby and significant distress to her parents".

    Separate to today's report findings, Nottinghamshire Police announced on Monday that two men had been arrested by officers investigating maternity failings in connection with operating practices at the city's mortuaries. They have since been bailed.