Review Findings
An independent review led by senior midwife Donna Ockenden, published June 24, 2026, uncovered systemic failings at Nottingham University Hospitals NHS Trust maternity services. Over 2,500 families and 800 staff provided evidence, revealing a pattern of avoidable harm and death. The review scored cases, finding 21.4% of maternal deaths, 26.1% of massive obstetric hemorrhages, and 12% of neonatal deaths were preventable with better care.
The report also highlighted a toxic workplace culture, staff shortages, racial health inequalities, and dehumanizing post-mortem care. Families reported dismissal of concerns and a lack of bereavement support. One early-gestation baby was disposed of as clinical waste against parents' wishes. Ockenden said services “failed the people it existed to serve” and described a “normalization of deviance” in care.
NUH Apology
Nottingham University Hospitals Chief Executive Anthony May and Trust Chair Nick Carver issued an open letter, unreservedly apologizing and accepting responsibility for the failings.
Recommendations and Martha’s Rule
The report outlined eight key themes for improvement, including listening to families, safe staffing, training, risk assessment, incident investigation, governance, and psychological safety. The UK government committed to rolling out Martha’s Rule to all maternity settings in England, giving families a legal right to an urgent independent review when they feel concerns are ignored.
“Safe, compassionate, and equitable perinatal care is achievable,” Ockenden said, “but only with unwavering commitment to accountability, learning, transparency, and basic human kindness.”