A landmark investigation into maternity services at Nottingham University Hospitals in Britain found chronic staff shortages, bullying, repeated dismissal of women’s complaints and serious medical failures that may have prevented more than 500 deaths or injuries to mothers and babies. The 401-page report examined about 2,500 cases from 2012 to 2025, making it the largest inquiry ever conducted in the NHS.
The inquiry said 444 women and 76 newborns suffered harm or potentially avoidable outcomes from substandard care, for a total of 520 serious cases. It found that in 260 cases involving babies who died or were injured, different treatment could probably have changed the outcome, including 155 infant deaths and 105 severe injuries. Donna Ockenden, the senior midwife who led the probe, said it was a report about "a system that failed, and the price of that failure. The price is lives, futures and families."
Investigators described failures across the entire maternity pathway, from pregnancy monitoring to delivery and postnatal care. Problems included poor fetal monitoring, misread CTG traces, failure to spot fetal distress, delayed tests and scans, weak escalation to senior doctors, and a persistent failure to investigate safety incidents properly. The report also documented 142 severe tears during birth, 130 unexpected intensive care admissions, 115 cases of major obstetric hemorrhage and 76 cases of severe pre-eclampsia. More than a third of women admitted to intensive care received care judged suboptimal.
Staff shortages were severe and longstanding, with 80% of workers saying there were not enough staff and 59% saying they regularly worked beyond scheduled hours. Some midwives had to care for several women at once, while neonatal intensive care nurses reported responsibility for up to nine babies simultaneously. The inquiry also found a toxic workplace culture marked by intimidation, racism and reluctance to challenge senior staff, with women, especially ethnic minorities and lower-income patients, often dismissed or blamed. Some families were also treated insensitively after deaths, including cases where babies’ bodies were mishandled after autopsies.
In response, the British government said it would extend Martha’s Rule to all maternity units, giving patients and families the right to seek an independent second opinion. Health Secretary James Murray called the findings "chilling" and "shocking," and said a wider public inquiry remains under consideration. Nottingham University Hospitals issued an unconditional apology and said it would be judged by its actions from now on.
