Publication of the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust

Today, Donna Ockenden has published the independent review into maternity and neonatal services at Nottingham University Hospitals NHS Trust.

This is a deeply distressing report. It describes years of serious and repeated failures in care, including poor leadership and culture, a lack of accountability, unacceptable racism and discrimination and women and families being disbelieved or dismissed. It also describes extremely serious failings in post death care – failures that caused grieving families further pain and trauma at a time when they should have been treated with the utmost care, dignity and compassion.

All of our thoughts are with the women, babies and families who were harmed, bereaved and let down, and with those who have fought for years to be heard. Every woman, baby and family has the right to safe, compassionate, personalised and equitable care, and to be listened to and taken seriously when they raise concerns.

The review has taken a continuous learning approach. Nottingham University Hospitals NHS Trust has responded to findings as they emerged and has already taken steps to improve care. However, the report shows the scale of what still needs to change.

One of the most important steps the Trust has taken is to listen to women and families, and every service in the NHS must do the same. Previous reviews have repeatedly shown that women and families must be heard, believed and have their concerns taken seriously and acted on. It is more important than ever that you work closely with your maternity and neonatal voices partnerships lead and local communities to ensure your services are set up to do this well to achieve this.

Immediate action announced today

The Government has announced immediate action in response to the review.

Roll out of Martha’s Rule to all maternity and neonatal settings in England.

The Government will be extending Martha’s Rule to all maternity and neonatal services.

Building on the learning and insights from the recent pilot, this next phase will support implementation in all antenatal, intrapartum and postnatal inpatient maternity and obstetric settings, including maternity triage and assessment units, and neonatal settings.

This is an important step in strengthening how we listen to and act on concerns raised by women, families and carers, and in supporting earlier recognition and response to deterioration. 

Implementation will be led by the national Martha’s Rule programme team, working closely with Patient Safety Collaboratives to provide coordinated local support, guidance and advice.

Strengthening candour and cooperation in future reviews

Once the Public Office (Accountability) Bill (or Hillsborough Law Bill) comes into force, the new duty of candour and assistance will be extended to apply to the independent maternity and neonatal reviews into Leeds Teaching Hospitals NHS Trust and University Hospitals Sussex NHS Foundation Trust. 

This will apply to current and former post holders and will require NHS staff asked to give evidence to cooperate fully, share relevant information openly and be honest about patient care, so families are supported to get the answers they deserve. For healthcare professionals, this reflects the expectations already set out in their codes of conduct.

However, regardless of any new legal duty, this report reminds us all how fundamental it is that there is a culture of openness, honesty and cooperation across the NHS. This means approaching our work with curiosity, compassion and transparency, to create the conditions in our units and services where women and families and staff are listened to, concerns are taken seriously and action is taken in response.

Human Tissue Authority (HTA) action requiring all Trusts to review mortuary records

The review identified serious failings in post-death care processes, including failures in mortuary systems, communications and information handling, which caused additional and avoidable trauma to grieving families.

The HTA will require trusts to review internal records from 2015 to 2026 as part of an assurance exercise on incident reporting.  We will write to trusts as soon as possible with further information and will also be writing separately to ensure that they have robust oversight of their own mortuary practices. 

The findings from this review and recommendations will be considered by the National Maternity and Neonatal Taskforce, alongside Baroness Amos’ national investigation, due to be published next week. The Government will then set out a full response to the national recommendations in September.

Although the Independent Maternity Review focuses on Nottingham University Hospitals, the issues it raises are relevant to the whole NHS. Every board should take time to read the report, reflect on its findings and consider what it means for its own services, leadership, culture, governance and approach to listening to women, families and staff.