A report published on Wednesday by senior midwife Donna Ockenden found that more than 500 mothers and babies died or suffered potentially avoidable harm at Nottingham University Hospitals NHS Trust between 2012 and 2025. The independent inquiry, the largest in the history of the National Health Service, examined over 2,500 cases and identified 156 baby deaths, including 94 stillbirths, and six maternal deaths. Health Minister James Murray described the findings as “chilling” and pledged an action plan by the end of the year, alongside the extension of Martha’s Rule to all English maternity wards.

The 401-page report documents a “bullying and toxic culture” sustained by a small group of leaders, where staff shortages were chronic and concerns were systematically suppressed. Women reported being told to “calm down” during labour, having their instincts dismissed as anxiety, and, in some cases, being denied adequate analgesia. The inquiry found that managers were aware of serious problems for years but failed to intervene, while internal investigations were designed to mislead families. One mother, Sarah Hawkins, a physiotherapist at the trust, described how her daughter Harriet’s stillbirth in 2016 was followed by a “systemic cover-up” that took a decade to unravel.

Viewed from London, the Nottingham scandal is the fifth major review of maternity failings since the 2015 Morecambe Bay report, with another rapid national review of 14 trusts due next week. Ockenden noted that recommendations from her 2022 Shrewsbury inquiry remain largely unimplemented. The report highlights that women from Black and minority ethnic backgrounds and those in deprived areas face the highest death rates, and that regulators appeared more focused on protecting clinicians than ensuring accountability. Murray told Parliament he was “appalled by the neglect, incompetence, racism, discrimination, contempt and harassment” suffered by families.

The government has committed to implementing Martha’s Rule, which guarantees patients an independent second opinion, in every maternity unit, and is considering legislation to compel current and former NHS staff to testify in inquiries, with penalties of up to two years’ imprisonment for non-compliance. The next factual milestone is the publication of the rapid review of 14 additional trusts, expected within days, which will indicate whether the systemic failures identified in Nottingham are replicated across England’s maternity services.