At least 156 babies and six mothers died at two maternity units run by Nottingham University Hospitals NHS Trust between 2012 and 2025. More than 500 families experienced potentially avoidable harm or loss. The independent inquiry examining those cases, the largest maternity investigation in the history of the National Health Service, published its findings on Wednesday.
The report was authored by senior midwife Donna Ockenden, who found a bullying and toxic culture at the trust’s two maternity hospitals, driven by what she described as a small minority of powerful leaders whose conduct infected the broader institutional environment. The consequences of that culture were measured in stillbirths, in babies who died shortly after delivery from oxygen starvation and hospital-acquired infections, and in families who were not told the truth about what happened to their children even after the deaths occurred.
Among the 94 stillbirths documented in the report was Harriet Hawkins, born in 2016. Her parents, Sarah and Jack Hawkins, were both senior clinicians at the trust at the time of her death. Ockenden described Harriet’s death as avoidable and found that it was compounded by a systemic cover-up and investigations designed to mislead. Jack Hawkins, speaking after the report’s publication, described a decade-long campaign to learn the truth as relentless and at times almost unbearable. His wife said she could not reconcile how the institution had treated them and the other families involved.
The cases included Wynter Andrews, whose parents were told in 2019 to terminate what was in fact a healthy pregnancy. Her father Gary Andrews recalled being told by a clinician that listening to every mother’s concerns would overrun the service. His response, delivered after years of advocacy, was that if the concerns had been listened to, hundreds of mothers and babies might still be alive.
Health Minister James Murray told parliament the findings were chilling. He said regulators had prioritised protecting clinicians over providing accountability, and described being appalled by what the report documented: neglect, incompetence, racism, discrimination, contempt, and harassment across more than a decade of care. He pledged a government action plan before the end of the year.
The Nottingham inquiry does not stand alone. Similar investigations at East Kent, Morecambe Bay, and Shrewsbury and Telford hospitals have exposed comparable failures in recent years, establishing a pattern that goes beyond any single trust. The question those inquiries have collectively raised, and which Wednesday’s report sharpens further, is whether the NHS has the institutional capacity to correct a crisis in maternity care that has now been documented, in one form or another, across multiple hospitals and over more than a decade.
The families involved already know the answer they lived through. What remains to be seen is whether the system has finally heard them.
