The publication of Donna Ockenden’s final report into maternity services at Nottingham University Hospitals NHS Trust marks another deeply troubling moment for patient safety in England. It is a deeply difficult read. At its heart are the experiences of thousands of families whose pregnancies and births did not go as they should have done, often with devastating consequences

The review examined 2,500 cases over a 13-year period. Those cases involved mothers and babies dying or being seriously injured, and stillborn babies. A total of 444 women and 76 newborn babies suffered potentially avoidable harm as a result of substandard treatment.

As clinical negligence solicitors we regularly act for families affected by avoidable harm during pregnancy and childbirth. The content of Ms Ockenden’s report is on the one hand incredibly shocking, but also regrettably familiar.

Key themes identified in the Ockenden report

The Nottingham review reinforces a pattern seen in previous maternity inquiries. What distinguishes this report is the scale of the failings identified within a single NHS Trust, and the clarity with which they are linked to organisational and cultural issues.

The report paints a stark picture of a service where basic standards of care were not consistently met. These include:

• Delays in recognising when a baby or mother needed urgent attention

• Lack of communication between teams, and

• an absence of clear senior input at critical moments.

In many cases, it was not one single issue that led to harm, but a series of smaller missed opportunities which, taken together, had very serious consequences.

It is within this broader context that the report also addresses issues of race inequality and discrimination in maternity care, a topic that continues to be identified as an issue across many Trusts.

Equally concerning is the report’s criticism of the Trust’s approach to learning and accountability. Families described being too often met with defensiveness rather than transparency, and feeling shut out, given incomplete answers, or left to find out the truth for themselves. Internal investigations failed to identify and address the true causes of harm.

Sadly, the experiences of the families harmed by Nottingham University Hospitals NHS Trust are not unique. Our clients often speak of a prolonged struggle to obtain clear answers, often only achieved through formal legal action. For families coming to terms with life-changing outcomes, this lack of honesty and openness can be just as distressing as the events themselves.

Race inequality

Unlike previous inquiries into maternity failings the Ockenden enquiry has explicitly named and detailed systemic racism and discriminatory workplace cultures.

The report has detailed harrowing examples of racism and discrimination not only to patients but towards staff as well. The inquiry found that:

• Staff frequently denied or withheld interpreters and translation services leaving vulnerable mothers unable to communicate their physical pain or understand their treatment options.

• Discriminatory pain stereotypes were held by the hospital staff of Black women being “able to tolerate pain” and South Asian women being deemed to “exaggerate or complain about pain more”. These dangerous stereotypes led to clinicians dismissing severe clinical symptoms which were found to directly contribute to the avoidable deaths of babies.

• Muslim families routinely had their requests for female-only clinical staff dismissed out of hand without justification, ignoring basic cultural dignity during childbirth.

• Families had their accents mimicked and were openly laughed at by senior staff members.

• Ethnic minority staff reported being intentionally sidelined and judged for their dress, appearance or background.

Ethnic minority families described facing a "brick wall" when trying to engage with the maternity unit. The staff mindset was described as: "We are not listening to you, you can't be in labour, we know what we are doing and you don't."

Similarly, non-white midwives and clinicians described experiencing micro-aggression and being targeted by senior managers. They talked of being silenced when they tried to raise the alarm about the unsafe care.

Sadly, the systemic nature of the racism and discrimination described within Nottingham University Hospitals NHS Trust is not exclusive to this Trust alone. It is something that has been identified for years in the national data from MBRRACE- UK, previous inquiries, and most recently in the Baroness Amos Interim Report into Maternity and Neonatal Services in England.

Real and lasting change is needed

The Nottingham report is another powerful reminder that maternity safety is not simply a matter of medical competence, but of culture, leadership, and accountability. For the families we represent, these findings will resonate deeply. While nothing can undo the harm that has already been caused, it is vital that these experiences lead to real and lasting change in maternity care.

The challenge now is ensuring that this report does not join the list of well-intentioned inquiries that fail to deliver lasting improvement. There have been numerous policy initiatives and a renewed focus on maternal health inequalities but, despite this, the systemic nature of the racism and discrimination within maternity and neonatal care leading to poor outcomes remains. A national approach is needed with specific metrics, targets and/or measurable objectives to ensure real actionable change.

Real change will require sustained commitment, transparency, and a willingness to confront uncomfortable truths. Until then, the role of the legal process in uncovering failings and securing accountability remains as vital as ever.