The Ockenden Report: A Regulatory & Professional Discipline Perspective

24 June 2026 saw the publication of Donna Ockenden’s review of maternity services at Nottingham University Hospitals NHS Trust[1]

Clyde & Co’s Sian Thompson & Evie Cullen provided a detailed article on the report here, but what could be the impact for individuals and those in the regulatory and professional discipline arena? This article will focus on the potential impact on regulated clinicians and touches on how we are already starting to see some individual disciplinary investigations linked to the Ockenden review.

A clear theme within the report is the tension between individual culpability and systemic failure; that harm primarily did not arise from isolated clinical error, but from ‘deeply embedded organisational deficiencies’ including failures in escalation, communication, learning and culture.

In a traditional regulatory framework, where the conduct of the individual clinician is isolated and examined, mitigating factors can be considered but there are calls for further guidance on the weight to be placed on mitigating factors when considering cases that arise out of investigations such as the Ockenden review. This is particularly so, given the findings that clinicians often worked within understaffed, high-pressure environments, that escalation pathways were unclear, or even that escalation was discouraged and where cultures of bullying or hierarchy inhibited staff from raising concerns.

The review repeatedly identifies failures that map directly on to existing professional regulatory standards, including failures to listen to patients and families, poor communication and a lack of compassion, failure to escalate concerns and inadequate recorded keeping. These obligations sit at the heart of Good Medical Practice 2024 and the NMC’s Code of Practice.

One of the most common findings across the review is a failure to recognise deterioration and escalate concerns in a timely way, which contributed to avoidable harm both to mothers and babies. Importantly, escalation failures were rarely presented as individual oversights, rather they were the product of cultural barriers, unclear governance and fear of challenge. This may result in more registrants submitting evidence of system-induced constraints and mitigation in cases where there is an alleged failure to escalate and regulators may be asked to carefully consider what, if any, action a registrant took to challenge a potentially unsafe department or culture.

We have seen team culture, leadership and communication come to the fore in the updated GMC standards, Good Medical Practice 2024. Emphasis has been placed upon the need to create a positive workplace culture, and the standards require doctors to be aware of the way in which their behaviour may influence others both inside and outside of their team (Paragraph 53).

The guidance also reflects the greater responsibilities of those within positions of leadership, in that they are required to ‘take active steps to create an environment in which people can talk about errors and concerns safety’ (Paragraph 79).  In light of Donna Ockenden’s findings of a toxic and hierarchical culture in Nottingham, it seems likely that there will be increased regulatory scrutiny of senior leaders in the medical and nursing fields in the coming years.

Here, it will be important to ensure that regulators distinguish between genuine leadership failings and the underlying drivers of harm over which it can be argued that individual clinicians had limited control. 

We may also see more registrants seeking to raise concerns about senior colleagues / managers as part of their defence to a fitness to practise concern and this will need to be balanced carefully to avoid giving the impression that the registrant is seeking to divert attention from their own actions or failures. 

The GMC has contributed to the Ockenden review, and Appendix 1 sets out an overview of the GMC’s involvement. Within this section, the GMC confirms that it has undertaken a systematic review and assessment of more than 300 draft case reports in order to identify potential fitness to practise concerns. It is therefore likely that a number of fitness to practise investigations will be opened in the near future and registrants will no doubt be anxious that their practice may soon be subject to further scrutiny.

Clyde & Co’s current experience is that fitness to practise investigations that arose separately from the Ockenden review are being held open until the review of all documentation obtained is complete, which is causing significant anxiety and delay for clinicians.

That said, while some cases are being delayed due to the GMC wishing to ensure there are no wider fitness to practise concerns arising from the Ockenden review, it is not yet clear how the GMC and NMC will determine how many of the hundreds of doctors, nurses and midwives involved are going to be investigated. This is a huge task, that risks holding individuals accountable for systemic failings, when we would argue that the two simply cannot be separated.

Assessments of individual accountability versus systemic dysfunction are not straightforward and certainly, this is not a new issue within healthcare regulation. The most high-profile recent debate in this area arises from the case of Dr Bawa-Garba which concluded with her returning to unrestricted practise in 2021. Since then, an analysis[2] of Medical Practitioners’ Tribunal decisions shows that wider contextual and systemic factors have been considered and acknowledged in recent cases, however there is no specific guidance as to how they should be weighed in the balance when considering fitness to practise.

It will be interesting to see whether the regulators now go on to develop guidance to assist in these cases involving complex systemic issues or findings from a widespread review such as Donna Ockenden’s, in order to develop a framework that fairly focuses on professional responsibility but recognises that in some cases, the system itself may be the primary driver of failure.

Guidance should perhaps also be issued on how the GMC and NMC plan to approach the task of identifying legitimate cases to be taken forward from an individual fitness to practise perspective. Neither regulator has the capacity to pursue hundreds of cases and with the Thirlwall inquiry due to report in the autumn and further Ockenden reviews underway, care will need to be taken in the selection of cases to avoid scapegoating clinicians in pursuit of being seen to take action. A principled approach must be established as disproportionate regulatory intervention is likely to significantly erode the relationship with a body of clinicians who have already been failed by the system within which they work. 

Of course, there will be some legitimate fitness to practise issues that arise from any large-scale review or public inquiry, but the regulators must not lose sight of the systemic problems and incredibly difficult circumstances in which clinicians were battling to provide care to their patients in Nottingham.

Clyde & Co's healthcare group is recognised for its extensive industry knowledge, offering a range of legal services covering public and private sectors as well as inquests, advocacy, professional regulation, product liability and pharmaceuticals/life sciences. Should we be able to assist you, please do contact one of our experts.