Ockenden report, as it happened: families call for public inquiry and say babies treated with ‘absence of dignity’

We are closing the live blog now, here is a recap of the day’s developments:

• More than 500 mothers and babies came to harm or died as a result of inadequate care in Nottingham, a report led by the childbirth expert Donna Ockenden has revealed. A total of 444 women and 76 newborn babies suffered “potentially avoidable” outcomes because they received substandard treatment over 13 years from Nottingham University hospitals NHS trust.

• The review, the largest maternity inquiry in the history of the NHS, found a “bullying and toxic culture” persisted at the trust over many years and impeded moves to improve care.

• Nottingham “does not exist in a vacuum”, Ockenden said at a press conference, as she warned of the “toxic culture” that took hold at the trust. “A pledge was made in 2015 to reduce the rates of stillbirths and maternal deaths in England by 50% by 2030. We are not on track,” she said.

• The trust chair, Nick Carver, and chief executive, Anthony May, who both joined in 2022, apologised in an open letter and said while improvements have been made, there is more to do. “We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services,” they said.

• The affected families have urged the government to launch a statutory public inquiry into maternity and neonatal services across England, as “safe care can only be only consistent when the full truth is known”.Add

• Health secretary James Murray apologised on behalf of the NHS, which he said “catastrophically” failed families who “suffered so appallingly” under maternity services at the trust. “To all of those who have suffered so appallingly, I say today on behalf of the NHS, I am sorry,” he said in a statement to the Commons.

• Addressing calls from bereaved families for a public inquiry, Murray said “no options are off the table”.

Read the full report here:

Back in the Commons, health secretary James Murray said “no options are off the table” as he was pressed by MPs for a public inquiry into maternity services at Nottingham University hospital NHS trust.

“I know that through my conversations with families, some families have wanted a public inquiry, others have had different views, but I can be very clear that for me no options are off the table,” he said.

At the press conference, Jack Hawkins said he is “troubled” by Lady Amos’s national maternity and neonatal investigation, which is due to be published next week.

He said: “We’re worried about the superficial nature of it. The point of a public inquiry is to find out what happened and we can’t find out what happened by interviewing 12 chief executives of very troubled hospitals.

“We have very little confidence in Baroness Amos. It’s not independent. It’s commissioned by the same people who allowed Nottingham to happen.”

The report has highlighted shocking instances of racism and stereotyping that mothers from ethnic minority and more deprived backgrounds experienced at the hands of staff within the Trust. Below are some of the more shocking examples:

• The review documented cases where life-threatening neurological symptoms in ethnic minority women were dismissed by staff due to bias. In one case, a woman from a north African background reported persistent headaches, slurred speech, and facial asymmetry, but hospital staff wrongly attributed her symptoms to “hormones” and ignored her family’s pleas for help. She later died from a brain tumour.

• In another case, a woman’s headaches, confusion, and incontinence were inappropriately attributed to mental health concerns and a “language barrier”; she also later died from a brain tumour.

• Young and teenage mothers faced explicit bias due to their age and social stigma regarding their circumstances. In one case from 2013, a young mother reported experiencing poor staff attitudes that were specifically related to her young age, while another’s baby died in the womb while her pleas regarding her heavy bleeding were dismissed.

• In one example, a doctor inappropriately asked a mother, “Why are you having another baby? You’ve had so many babies before,” which caused the mother significant distress and depression

• Staff members also admitted to witnessing “covert racism to black/brown women” and mothers reported facing a “toxic blame culture” and being stereotyped by staff as being “loud” or “too demanding” when trying to advocate for themselves.

James Murray, the health secretary, is addressing the Commons on the findings of Ockenden report, describing them as “chilling”.

He said: “Donna Ockenden’s review is the largest ever into a maternity service in the history of the NHS.

“The nature and sheer scale of the failings it exposes are horrific. It uncovers dangerously and tragically deficient care at almost every turn.”

He apologised on behalf of the NHS, which he said “catastrophically” failed families who “suffered so appallingly” under maternity services at Nottingham University hospitals NHS trust.

He told the Commons:

The driving force behind this review has been the affected families themselves. They have demonstrated more patience, more courage and more tenacity than one might imagine is possible from those dealing with broken hearts that will never mend.

And whilst each of their experiences unique, one feature is common: at the very moment that they were at their most vulnerable, they placed themselves and the lives of their unborn babies in the hands of the NHS, and the NHS failed them catastrophically.

To all of those who have suffered so appallingly, I say today on behalf of the NHS, I am sorry.

I am sorry, not just for the failures or the heartless and undignified treatment, but also because your cries of concern went unheard for too long.

And so the government will act. We will act by taking immediate steps, including to expand Martha’s rule to all maternity in neonatal settings, so that parents can demand a second opinion if they feel their concerns are being ignored.”

Here is an extract from Jack Hawkins’ statement:

After a relentless and at times almost unbearable 10-year campaign, it is with a profound sadness and a deep sense of anger we learn the true scale, the extent, of the maternity scandal.

Our concerns were dismissed and not acted upon. We weren’t told the truth about what happened, even after death.

He added:

Babies were treated with an absence of dignity and the hospital frequently failed to keep our loved ones safe.

We never wanted to be campaigners. We are victims. We became campaigners because those responsible for keeping mothers, babies and families safe failed to listen.

The report, findings and actions that Donna and her team say must happen must be treated with the utmost seriousness and implemented in full. Anything less would be a betrayal of families whose suffering has made this review necessary.

Sarah and Jack Hawkins were one of the first families to raise the alarm about failings at Nottingham University Hospitals (NUH) NHS Trust after their daughter Harriet was stillborn in 2016.

At a press conference in Nottingham, Sarah Hawkins said a public inquiry is needed to ensure medical staff are compelled to give evidence.

In a statement, read out by Jack Hawkins on behalf of the bereaved families, he criticised a number of senior staff in Nottingham who did not cooperate with the review and said this was “proof” they were “unfit to keep mothers and babies unsafe”.

Sarah said a public inquiry would ensure such staff were compelled to give evidence, adding she was in contact with affected people from Leeds to Plymout. There is no accountability for NHS staff who have “harmed or killed a child or mother,” she said.

“When your kid dies, no one really wants to talk about it. But when your kid dies via NHS negligence, hardly anyone wants to talk about it and I really want to change that because sadly it is very common today,” said Sarah Hawkins, whose daughter Harriet was stillborn at Nottingham City hospital in April 2016.

The bereaved families said they have heard similar stories from Leeds as far south of Plymouth – yet another reason why it’s so important for there to be a public inquiry into maternity and neonatal services across England.

The affected families are urging the prime minister to launch a statutory public inquiry into maternity and neonatal services across England, as “safe care can only be only consistent when the full truth is known.”

The affected families have begun speaking. Watch here:

Some of the affected families are scheduled to speak to reporters soon. Please stay tuned to hear their stories and reactions to the report.

In an address to affected families and journalists in Nottingham on Wednesday morning, Ockenden said there was a “persistent failure to listen to and believe mothers and fathers” by maternity services, as well as a failure to investigate mistakes and learn from them.

Many of the bereaved and affected families in the room were emotional during Ockenden’s statement. The chair paid tribute to them and said: “This review owes its very existence to a group of families who refused to be silenced – they came together in harm and in grief – united in their determination to what had happened to them should not happen to anyone else”.

She also spoke about the testimonies from parents who described “milestones their children never reached”. “I have heard relationships shattered, careers lost, mental health broken by what happened, and sometimes by what came after when the truth was withheld and accountability was denied,” she said, adding there is a “particular cruelty in preventable harm”.

Ockenden added: “This report is about what happens when leadership fails, when governance fails… bullying tolerated, concerns are repressed, incidents downgraded and the voices of women, particularly the most vulnerable, are systemically dismissed…

“This is a report about a system that failed and it is a report about what it costs when systems fail. It costs lives, it costs futures and and it costs families everything”

Charities supporting bereaved parents and women who have experienced birth trauma have set up stalls outside the media briefing room to support the affected families.

A minute’s silence was held at the end of Ockenden’s statement for the “mothers and babies who had died”.

Ockenden concluded her address calling for “collective action” and said progress needs to be “sustained, deepened and built upon.”

Thirty-one of the detailed examinations of the deaths of newborn babies found that they had received inadequate care and that, if they had been handled differently, they would probably have avoided coming to harm.

The report lays bare a host of recurring failings in clinical care that put mothers and babies at risk and in some cases had catastrophic consequences. They included:

• Repeated failures to monitor babies properly during labour,

• Misinterpretation of CTG trace-reading of the baby’s health while still in utero,

• Not recognising when babies were in distress,

• Midwives not escalating worrying cases urgently to doctors to make rapid decisions on the care and treatment needed.

“In a number of cases these failures contributed to severe neonatal injury, stillbirth and neonatal death,” Ockenden’s report says.

Read more:

The chair of the Nottingham University hospitals NHS trust, Nick Carver, and chief executive, Anthony May, have issued an open letter in response to the Ockenden report.

Addressed to “the people and communities of Nottinghamshire”, they apologised and said while improvements have been made, there is more to do.

Here is the letter in full:

The publication of the independent review into maternity services in Nottingham is a watershed moment for affected families, our staff and for the communities we serve. We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services.

We failed you, and on behalf of Nottingham University Hospitals Trust, we accept responsibility for our failings.

Many families have been generous enough to meet with us, showing extraordinary courage and determination. We are grateful for that, and we want you to know that the publication of this report is not the end of a process. It is another important milestone in a journey that must continue. Your bravery and commitment to speaking up is helping improve maternity care.

We want to thank Donna Ockenden for her work and for engaging with us throughout this process. Donna’s review has provided an opportunity to hear directly from thousands of families and staff. The direct feedback we have had throughout has helped us with our improvement efforts. As a result, whilst there is more to do, important changes have been made and we believe our services are now safer, kinder and better led.

We recognise that trust is earned through actions, not words. We know, also, that families and the wider public will judge us not by what we say today, but by what we do next.

The review makes clear that while improvements have been made, there is still more to do. We will take time to reflect on the report with humility, honesty and determination. At the same time, we will work with families on a meaningful apology because we know it is important to them that this is reflective of the findings of the review, and our commitment to lasting improvement. We can say with certainty that families will continue to be involved in our improvement plans because this review has proved that we can learn from them.

We must also acknowledge our staff. Every day we see dedicated, compassionate professionals working tirelessly to provide the best possible care for women and families, often under extreme pressure and scrutiny. Whilst the publication of the report will be difficult for them too, we know they will reflect on the findings of the review and see this as an opportunity to continue our improvement journey. To these colleagues, we want to say that we know that we did not always provide you with the right conditions to do your jobs as you would wish and we take responsibility for that.

At Nottingham University Hospitals, we are determined to provide maternity services that are consistently safe, compassionate, equitable and responsive. We want every family to have confidence in the care they receive. We want to reassure anyone using our services today that you will be safe in our care.

On behalf of the trust, we renew the commitments to transparency, openness and accountability. Most importantly, we renew our commitment to providing safe, high-quality maternity care at your hospitals.”

Nottingham “does not exist in a vacuum”, Ockenden said at the press conference, as she warned of the “toxic culture” that took hold at Nottingham University hospitals NHS trust.

She said:

A pledge was made in 2015 to reduce the rates of stillbirths and maternal deaths in England by 50% by 2030. We are not on track.

Stillbirths, whilst reduced over recent years, remain above pre-Covid pandemic levels. Maternal deaths are at a 20-year high and the women most at risk, women living in the most deprived communities and black women, continue to die at rates that are a national scandal.”

That disparity is well known, but it has not narrowed.

She added:

What the evidence shows is that at Nottingham, a toxic culture was allowed to take hold and was allowed to persist.

A small number of powerful leaders, described in both family and staff testimonies as having infected the unit, created an environment in which bullying was normalised, speaking up was dangerous, and governance was shaped by self-protection rather than patient safety.

Midwives describe being intimidated in governance meetings, junior staff described to us being afraid to escalate. The incident review panel was described as intimidating, male-dominated and dismissive of non-medical voices over very many years.

Staff described to us leaving the trust because incidents were being brushed under the carpet.

Ockenden said the report also addresses “clearly and with evidence the inequalities that shaped who was most harmed”.

These included women from black, Asian and other minority ethnic backgrounds, those living in deprived areas of Nottingham and Nottinghamshire, women with mental health needs, and women who did not speak English as a first language.

“These are amongst the women who face the greatest barriers to being heard, and who were most likely to have their concerns dismissed or minimised,” Ockenden said.