The Ockenden Report: A review

On 24 June Donna Ockenden’s Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust was published. This is one of a series of high-profile reviews of maternity services in the NHS and considers the care provided by the Trust between 2012 and 2025.

The report highlights failings at management level (such as funding, staffing and a failure to act on concerns) and also in respect of on the ground care with failings to listen to parents, investigate and learn from mistakes. Donna Ockenden, a former midwife, calls for a rigorous system of regulation that is easily accessible and responsive alongside a renewed focus on professional conduct and self-regulation among staff. In calling for this she recognises that on a wider level many of the systems of oversight established for maternity care are no longer fit for purpose.

The report looked at the experiences of more than 2,500 families and the investigating team spoke with more than 800 current and former clinicians, midwives, nurses and other healthcare professionals at the Trust.

A theme running through the report is one of communication and reflection; not only when care has gone badly but also when care has gone well so that in each circumstance learning can be identified and applied to future care to improve the experience for families and allow for a change in culture from one of blame to an open and respectful environment for all those involved in maternity care.

The report considers not just the role of the clinicians on the ground providing day to day care but also the role of senior and executive managers who were identified in the report as either ignoring or being unable to respond to the concerns being raised. Donna Ockenden acknowledged that since the report was commissioned in 2022 there have been significant improvements in some areas of care such as triage and fetal monitoring. There has also been an implementation of deliberate measures to strengthen visible clinical leadership within maternity services in recognition of the fact that for the period covered by the review, the investigators had identified prolonged periods of maternity leadership instability and fragmented governance arrangements.  Measurable progress in leadership, workforce development, culture, training and learning was recognised in the CQC inspection published in 2026.

Nottingham University Hospitals Trust is one of the largest and most complex maternity providers in England delivering a broad spectrum of care, supporting women and babies with routine and complex needs within a diverse population in terms of both ethnicity, social factors and age spectrum. The report acknowledges that the context within which the maternity care in Nottingham was being provided is relevant to the findings of Donna Ockenden and her team.

There is a chapter in the report on “addressing inequalities in care” which focusses on considering the experience of families from Black, Asian and other global majority groups including those living in deprivation and social disadvantage. Over recent years there has been a growing awareness of how families are having different experiences within maternity care. The report references national data which shows that women from black ethnic groups are almost 3 times more likely to die during pregnancy or up to 6 weeks post-partum compared with white women, while women from Asian ethnic groups experience approximately twice the risk. This issue has been highlighted by the Royal College of Obstetricians and Gynaecologists and also by the Royal College of Midwives. Both bodies have called for maternity systems to be redesigned to ensure that a woman’s ethnicity, migration status or postcode does not determine her or her baby’s safety.

Amongst the heartbreaking stories of the families who experienced poor care the report includes recognition that there are examples of excellent personalised and compassionate care. The report references that many staff working in the Trust were also affected by the harm experienced by families and it includes a chapter relating to the “staff voices” who contributed to the review. These staff raised as their biggest area of comment the pressures and consequences of short staffing.

The report is a comprehensive review of all areas of the maternity provision at Nottingham from antenatal care through to labour and postnatal care, neonatal services and bereavement care.

The report concludes with a list of 8 key headings encompassing 18 immediate and Essential Actions (IEAs) following publication. The IEAs present a checklist for all NHS Trust’s to consider when looking at how to improve their maternity offerings. Unsurprisingly given the overall theme of the report the first priority relates to listening to women and families and makes it clear that there is a need to ensure that women are provided with clear, consistent and accessible information to support them in making informed choices. This information should be available in a range of formats and languages. There should also be a mandatory field on any proforma triage documents where staff are required to record the woman’s account.

IEAs 2 to 5 are clinician related and call for a nationally agreed perinatal workforce planning methodology suitable to account for local variation but also providing a consistent national framework. Included within this is the need to ensure appropriate staffing levels or staff with the requisite skills. There should also be implemented a nationally recognised Labour Ward Co-Ordinator programme and it should be ensured that staff receive regular and appropriate training. While on some level these IEAs are for consideration at a scope beyond Trust level thought should be given by individual Trusts as to steps they can take that would be considered inline with these recommendations.

IEAs 6 to 14 relate to appropriate risk assessments for the most common presentations by women in maternity services as well as ensuring that when things do go wrong there is a frame work and culture of investigation and feeding back. This will be important for Trusts to evidence.

IEAs 15 to 17 focus on creating an environment from the top down in which it is considered safe for issues to be raised and addressed and there is a requirement  for every Trust to appoint a maternity subject matter specialist to represent the views of the multi-disciplinary team at trust board level. This will be important to provide Boards with on the ground oversight.

IEA 18 relates to mothers who have sadly died and post death care. There are clear recommendations as to where post mortems are conducted and that paediatric post mortems are only performed by specialists.  If there are to be reviews into after-death care these should include an independent post-death care specialist.

Donna Ockenden made it clear that she expects these IEAs to be actioned and “will be watching”. Implementation of the IEAs will undoubtedly result in safer maternity services which will be welcomed by families and those providing maternity care.

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