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Reviews / 2026

Independent reviewPublishedMaternity and neonatalEngland

Independent review of maternity services at Nottingham University Hospitals NHS Trust

Donna Ockenden · work from 2022 · published 2026

What this was

Independent maternity review led by Donna Ockenden, commissioned in 2022 and published on 24 June 2026. It looked at care from 2012 to 2025. More than 2,500 families and more than 800 staff contributed. The review identified potentially avoidable harm, failures of staffing, a failure to listen to parents, and a failure to investigate and learn. It made local actions and 18 immediate and essential actions for maternity services in England.

Why it sits in the hub

It is Shrewsbury again, in another trust, after the essential actions of 2022. The overlap is the point: workforce planning, listening, escalation, fetal monitoring and learning were not embedded.

Findings

  1. Finding 1

    Families described not being listened to or believed. Staff described being unable to complete even basic training because of staffing.

    Listening to patients and familiesSafe staffingTraining and competence

  2. Finding 2

    Harm was not reliably investigated, so the same failures recurred.

    Learning from harmMaternity and neonatal care

Recommendations in this hub

The source reports 18 recommendations or essential actions. The notes below are a paraphrase, not the official text.

  1. 1Awaiting responseMaternity services

    Give women clear information and a real choice, including about labour, pain relief and interventions.

    Listening to patients and familiesMaternity and neonatal care
  2. 2Awaiting responseNHS England

    Use a workforce method that reflects complexity and deprivation, not birth numbers alone.

    InequalitiesSafe staffing
  3. 3Awaiting responseTrusts

    Set a national standard for labour-ward coordinators, including feedback on how their behaviour affects the team.

    Leadership and boardsTraining and competence
  4. 4Awaiting responseTrusts and royal colleges

    Standardise assessment of fetal growth, triage, maternal early-warning scores and the recognition of deterioration.

    Data and early warningMaternity and neonatal careTraining and competence
  5. 5Awaiting responseNHS England and trusts

    Fund the Patient Safety Incident Response Framework properly, and build a learning culture that families can recognise as compassionate.

    Culture and conductLearning from harm
  6. 6Awaiting responseTrusts

    Set standards for care after a baby dies.

    Bereavement careMaternity and neonatal care