According to the review, by 2023 there were indications that maternity services in Nottingham were starting to improve.

The report states: "While these improvements are important to recognise, they must be understood within the context of longstanding and systemic failures, the impact of which continued to be felt by families and staff."

During this period, the report said, NUH also began to "acknowledge more openly the scale and duration of previous failings".

It added: "Public statements included apologies to affected families, including the family of Wynter Andrews, recognising deficiencies in care and failings in the handling of investigations."

In January 2023, NUH was fined £800,000 after admitting failings in the care of Wynter, who died after 23 minutes.

Gary and Sarah Andrews, bereaved parents to baby Wynter, both said full accountability was now needed from those who declined to take part in the review.

"Having spent so many years fighting and being ignored, it's a relief knowing that you’ve been listened to," Sarah said. "Everything that we've been saying for years is true.

"Maternity services will not improve until there is full accountability, and we need answers from the regulators."

Gary added: "We met with a lot of the families and the key themes you hear in the report, we have lived experiences of that.

“It was striking to me 800 members of NUH staff were involved in the review – it shows they want positive change.

“But the lack of engagement from senior leaders – some still working in the NHS - is staggering.”

Image source, George Torr/BBC

The report said "significant staffing gaps" at this point remained - including a midwifery deficit exceeding 120 whole-time equivalent roles, together with a shortage of obstetricians.

Reviews and staff feedback continued to identify issues, including bullying, poor behaviours, and a lack of effective learning from incidents suggesting that despite the scale of external scrutiny, these cultural and governance challenges had not yet been resolved.

A defining feature of this period was the increasing organisation and mobilisation of affected families, the report said. A letter from 100 families was sent to the then Health Secretary Sajid Javid expressing a lack of confidence.

Leadership changes during this period sought to stabilise the organisation. A new director of midwifery was appointed in July 2022, followed by the appointment of a permanent chief executive in September 2022.

While these appointments were important in establishing new leadership, they occurred within the context of significant organisational change and did nothing to raise confidence among families and staff, the report added.

By 2020, concerns about maternity services at NUH had escalated to a critical level requiring rigorous external investigation.

The events between 2020 to 2021 indicated maternity services at NUH had "reached a point of systemic failure", the report said.

Concerns were no longer limited to internal reporting or isolated incidents, but were reflected consistently across regulatory findings, national investigation bodies, and formal oversight mechanisms.

Between April and July 2021, three babies died while under the care of NUH. In each case, failings in care were identified as contributory.

They resulted in a landmark prosecution by the CQC, with a coroner describing the trust as "obstructive" in relation to delays in disclosing evidence, compounding the distress experienced by families.

In 2017, both the chief executive officer and the chair resigned following a critical "well-led review", led by the Care Quality Commission (CQC).

Although some improvements were reported, there is "limited evidence" that these resulted in sustained or embedded change, the report said.

Several babies died or suffered harm during this period, with incidents often revealing recurring themes: delayed escalation, poor monitoring, and insufficient staffing.

In 2018, 50 maternity staff submitted a formal letter to the trust board chair, raising concerns about staffing levels and patient safety, which represented a significant escalation from reporting to the leadership team.

By 2019, NUH was at risk of being placed into special measures.

We’ve been hearing from some of the families affected by the Nottingham maternity scandal.

Emily Stringer's daughter Caitlyn suffered a serious brain injury when she was born four years ago. She said due to her poor care, her daughter cannot walk or talk and is partially sighted.

She told the BBC: “It’s the validation that we never wanted but it’s amazing to have.

“Our family and 2,500 others in Nottingham have been heard - we are not the isolated case the trust tried to make us out to be.

“Many staff members have suffered real physiological harm - they need to be supported. The perpetrators of the toxic bullying culture need to be held to account.”

Image source, George Torr/BBC

By 2015, according to the report, concerns regarding maternity services at NUH had now moved beyond early warning signs and were being raised more explicitly within governance structures.

Evidence presented to the trust board indicated ongoing safety concerns, including workforce pressures, cultural issues, and weaknesses in escalation processes.

Despite this, reassurances were provided that clinical outcomes were "satisfactory" and "operating safely".

During this period, significant concerns were raised regarding staffing levels, particularly in midwifery. It was alleged that preparations for regulatory inspection and a CQC visit had been managed in a way that did not reflect operational realities.

The full, published report also takes us through a timeline of Nottingham University Hospitals (NUH) NHS Trust's maternity problems.

The review found that from 2010 onwards, a "series of indicators" began to emerge, which pointed to "underlying weaknesses in governance, leadership and organisational culture" within NUH.

These issues were identified through a combination of internal reporting and staff feedback.

The findings indicated there were already clear warning signs of "systemic weaknesses" within the trust dating back to the early 2010s.

"While each issue in isolation might not have indicated a system-wide failure, the culmination of issues over time should have prompted earlier and more decisive intervention," the review said.

Donna Ockenden has now concluded her second press conference of the day.

Donna Ockenden was also asked to elaborate on her comment from this morning's press conference that she would be “watching NUH really closely”.

She explained she does not want a repeat of a situation in Shrewsbury when families contacted her in 2022 - two years after her review of their maternity services - to say there had been no engagement since.

“I didn’t think I would have to go back [to Shrewsbury], but I did," she said.

“Myself and a very small team on a part-time basis will help the [NUH] to set up a process of learning and improvement.

“It’s going to be an ongoing process and I will continue to spend some time in Nottingham over the next 18 months to two years.”

Donna Ockenden has been answering questions from media at a press conference in the main function room of the Crowne Plaza Hotel.

She has been asked why she did not name the chief executives or the staff members who were involved in the bullying of maternity colleagues.

Ockenden said there was a balance to try to protect staff on the ground, who she praised for coming forward to share information in their hundreds.

She added it was “chalk and cheese” between the engagement of staff on the ground compared to the chief executives.

“We did the best we could, we got some very good staff engagement, but we recognise there are people who should have talked but chose not to… they won’t get away with it in future,” she said - a reference to plans to bolster rules around compelling NHS leaders to give evidence at upcoming maternity reviews in Leeds and Sussex.

“What we were told clearly from ordinary staff on the ground, over many years, they were raising concerns about safety, about staff burnout and they did not have the resources they needed," she said.

“But yes, there are gaps in our knowledge because people who needed to come forward did not.

“We don’t know why they didn’t engage.”

The inquiry details serious maternity failings at Nottingham University Hospitals NHS Trust dating back to 2010 - but who has been in charge over those years?

Dr Peter Homa served as chief executive from 2006, with his organisation categorised as a "high risk trust" by the Care Quality Commission in 2013.

After he stepped down in 2017, he was replaced by former nurse Tracy Taylor. A year later more than 50 maternity staff signed an open letter warning maternity services were in crisis.

Taylor left in 2021 and Rupert Egginton took on the top role on an interim basis before Anthony May took charge in September 2022 - a few weeks after Ockenden's review got under way.

May has pledged "transparency" and "full engagement" as the trust seeks to recover from the serious failings detailed in the review.

Canterbury MP Rosie Duffield, chairwoman of a parliamentary group on birth trauma, has echoed calls for a statutory public inquiry to stop the NHS "lurching from crisis to crisis".

She described maternity care as a "postcode lottery", with ad-hoc inquiries into failures at specific trusts failing to deal with a national problem.

She said: "It's really a question of how does your particular trust perform?

"Are you lucky enough to live somewhere where it's safer than somewhere else, which is awful?"

Local Labour MPs have issued a joint statement following the publication of Ockenden's review.

They say the report reveals "failures and harm that should never have happened, and identify issues that require urgent action".

The statement added: "Today is not the end of this process. It is the beginning of the next chapter.

"Our immediate focus is on the families at the heart of this review. We recognised that many will still be processing the findings and reflecting on what has been an emotional and deeply significant day.

"We want to give families the time and space they need and deserve. When the families are ready, we will meet with them again.

"We will listen carefully to their views and concerns, and together we will continue to advocate for whatever action is necessary to secure answers, accountability and justice they are still fighting for."

The statement is signed by Sherwood Forest MP Michelle Welsh; Gedling MP Michael Payne; Mansfield MP Steve Yemm; Erewash MP Adam Thompson, Nottingham North and Kimberley MP Alex Norris, North West Leicestershire MP Amanda Hack; Rushcliffe MP James Naish; Bassetlaw MP Jo White; Broxtowe MP Juliet Campbell; Nottingham South MP Lilian Greenwood; and Nottingham East MP Nadia Whittome.

Verity Cowley
Presenter, BBC Radio Nottingham

A total of 550 people involved in the Nottingham maternity review have been referred for psychological support.

Jen Moon (above), from the Family Psychological Support Service, said it would continue to accept referrals after the review had been published, and were able to offer a service to "anyone in the family who's been impacted by the Ockenden review".

Vinnie Irvine - who uses the support service - said he was traumatised after witnessing a complicated birth.

Speaking of the service, the father said he had learned techniques to "ground" himself when things start to "well up".

Nottinghamshire Police launched Operation Perth in September 2023 into failings that led to hundreds of babies dying or being injured.

Then, in June 2025, the force confirmed it had opened a corporate manslaughter investigation and said it was examining whether maternity care by NUH had been grossly negligent.

In January of this year, a member of police staff resigned after "deleting or altering" information as part of the investigation.

At the time, the force said an investigation found no evidence of misconduct, and determined the individual "did not act dishonestly or maliciously" and there was no evidence of third-party involvement.

The scope of Operation Perth was expanded in March to include potential offences committed under the Offences against the Person Act and the Abortion Act.

On Monday, police arrested two men in connection with operating practices in the city's mortuary service.

The men, 55 and 59, who were detained on suspicion of misconduct in the public office, were bailed on Tuesday.

On Wednesday, Deputy Chief Constable Rob Griffin added: "The publication of the independent maternity review report does not mark the conclusion of Operation Perth.

"We will consider the report's findings closely as part of our wider ongoing investigation."

Luke Mintz
World at One reporter

Sir Jeremy Hunt, the former health secretary, has said he fears Donna Ockenden's review into maternity care could be "yet another report that ultimately gathers dust", unless the NHS takes serious action.

Speaking to BBC Radio 4's World at One programme on Wednesday afternoon, Sir Jeremy said: "The NHS is the world champion at doing these reports and then not doing anything to implement them."

Asked about Ockenden's findings, he said: "The sad truth is that a lot more of this is common across the NHS than we might like to think.

"We're seeing a pattern now. It's time the NHS sets up a structured system so that when you have these public reports, when you have recommendations from select committees, from coroner's courts, something actually happens.

"That is the thing that is not happening at the moment. And unless that is addressed, I'm afraid this will be yet another report that ultimately gathers dust."

But Sir Jeremy also said he was "reluctant" to back calls for a full statutory inquiry in Nottingham maternity failings.

He said: "That's another five years, and that's another excuse for ministers to say 'well, we've got to wait until the public inquiry reports, and then we'll make our decisions'."

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Lizzy Bella
BBC Newsbeat

Mollie Sutton has been waiting for the outcome of today's inquiry.

She believes mistreatment by medical staff during her labour at a Nottingham hospital in 2018 led to her son Rupert being disabled.

The mother of three, who is now 27, shared her experiences with Donna Ockenden's team.

"Throughout my entire labour, there was neglect and failures," she told BBC Newsbeat. "I was being verbally abused by my midwife, I wasn't given any privacy or dignity."

Mollie has been fighting for her son - who she said had the mental capacity of a four-month-old - for years and said she wanted the inquiry to lead to improvements.

"What we want and we really need is accountability and justice," she said. "We need change to happen fast."