The story behind the largest maternity review in the NHS

The maternity units at Nottingham's two major NHS hospitals are the focus of the largest inquiry of its kind in NHS history.

Hundreds of babies have died or been injured while under the care of Nottingham University Hospitals (NUH) NHS Trust, which runs the departments at City Hospital and the Queen's Medical Centre.

The inquiry, which began in 2022, has heard from 2,500 families and about 850 members of staff.

It also prompted a national investigation into maternity care in England, though this has itself prompted controversy.

The NHS has already paid out more than £100m over failings at these centres between 2006 and 2023.

One of the first families to raise the alarm was Jack and Sarah Hawkins, whose daughter Harriet died in the womb at City Hospital in April 2016.

The BBC revealed that 18 days before Harriet's death, serious concerns had been raised around culture at the hospital where she died.

Jack and Sarah, who both worked for the trust, did not accept a hospital review that found "no obvious fault", and stated their child had died of an infection.

The couple pushed for an external review, which began four months later.

Published in January 2018, it found 13 failings and concluded the death had been "almost certainly preventable".

In the same year, midwives at the trust drafted a letter that would later form part of an inquest into the death of another baby, Wynter Andrews.

She died 23 minutes after being delivered by Caesarean section in September 2019.

At the inquest the next year, assistant coroner Laurinda Bower told Wynter's parents, Sarah and Gary, that her death had been "a clear and obvious case of neglect".

Bower cited the 2018 letter, from midwives on the unit to NUH bosses, which had outlined concerns over staffing levels as "the cause of a potential disaster".

In December 2020, two months after Wynter's inquest, the trust's maternity services were rated as inadequate by the healthcare watchdog, the Care Quality Commission (CQC).

The report found some staff had not completed training in key skills and "did not always understand how to keep women and babies safe".

Inspectors added there was "limited evidence of managers monitoring the effectiveness of care and treatment and driving improvement".

This prompted both the Andrews and Hawkins families to call for a public inquiry.

Calls increased in July 2021, when Channel 4 News and the Independent reported that 46 babies suffered brain damage and 19 were stillborn at the trust between 2010 and 2020.

Plans for a review, led by the local clinical commissioning group (CCG) and NHS England, were announced that month and with the intention of reporting back by November 2022.

By March 2022 it had been in contact with nearly 400 families, but it had already been criticised by campaigners for what they saw as a lack of independence, experience and "moving with the viscosity of treacle".

It was at this point that families called for Donna Ockenden to take charge of a fully independent review.

Ockenden had recently completed the inquiry into what was, at the time, the UK's biggest maternity scandal, at Shrewsbury and Telford NHS Trust.

Her appointment was confirmed in July 2022, with the review of care provided by the trust being launched in September the same year.

By July 2023, the review had become the UK's largest.

In May 2024, the scope of the review was expanded from examining stillbirths, neonatal deaths, injured babies and mothers and maternal deaths, to antenatal care - all contact mothers have with maternity services until their children are born.

Bosses at the trust have repeatedly apologised for failings and the chief executive Anthony May, who took up his post in 2022, said NUH was committed to "transparent and full engagement" and improvements to staffing, training and compliance with guidelines.

The Ockenden review closed to new cases in May 2025, with Ockenden saying she was on track to publish a report on her findings in June 2026.

Nottinghamshire Police announced it would be launching its own inquiry into the failings in September 2023.

Operation Perth, as it was called, is running alongside the independent review and assessing all the material it provides.

In June 2025, the force announced it had launched a corporate manslaughter investigation as part of Operation Perth, examining whether maternity care provided by the trust had been grossly negligent.

The £101m in compensation and legal fees paid out due to maternity failings was revealed in February 2024.

The payments related to 134 cases, with one family - whose son was left with cerebral palsy - fighting a 10-year battle for a package of an initial £6m and annual payments thereafter.

The NHS has paid out for 22 cerebral palsy cases at NUH, amounting to £53.1m in legal fees and damages in the last 17 years.

Stillbirth was the second highest figure at £4.6m, followed by successful claims of bowel damage (£3.4m), bladder damage (£2.2m) and fatality (£1.9m).

The Hawkins received £2.8m - the largest compensation settlement in a stillbirth clinical negligence claim in NHS history, five years after the death of Harriet.

NUH was also given a fine of £800,000 by magistrates in January 2023 after admitting failings over the death of Wynter Andrews.

Until 2025, that was the largest fine handed down for maternity care failings, but in February, the trust was fined £1.6m over failings in connection with the deaths of Adele O'Sullivan, Kahlani Rawson and Quinn Lias Parker.

The trust pleaded guilty to six counts of failing to provide safe care and treatment to the babies and their mothers, and the court heard there were similar failings in all three cases.

Following the latest inspection of maternity services at Nottingham City Hospital and the Queen's Medical Centre, the CQC rates both as requires improvement overall.

Bereaved parents and families have repeatedly called for a national maternity inquiry, including the Hawkins, who signed an open letter urging the then health secretary Steve Barclay for a judge-led, statutory public inquiry.

At the time, Jack said: "We have had repeated inquiries and it's the same issues that keep on coming up.

"There is a fundamental problem with maternity services in this country.

"We need to understand it. At the moment it feels like you can cause horrific damage to someone's family and it doesn't really register, it doesn't matter."

While a new health secretary, Wes Streeting, stopped short of a statutory public inquiry, he announced in June 2025 a national "rapid" inquiry of maternity services.

In a speech at the time, Streeting said he had been meeting bereaved families over the past year who had "deeply painful stories of trauma loss and lack of basic compassion".

He said: "Their bravery in speaking out has made it clear: we must act - and we must act now."

The review - headed by Baroness Amos - is investigating 12 NHS trusts as part of the work, while undertaking a system-wide look at maternity and neonatal care to create a set of actions to improve it across every service.

Responding to the announcement, Ockenden said: "It is encouraging to see that the secretary of state is listening to and supporting so many families from across the country.

"These are families who have campaigned tirelessly for accountability, truth and meaningful improvements in safety."

Later that month, the General Medical Council (GMC), which regulates doctors in the UK, and the nurses and midwives regulator - the Nursing and Midwifery Council (NMC) - issued a public apology to harmed families, with an NMC boss saying it "did not engage with families well enough".

The NMC told the BBC it currently has 12 family cases referred to it relating to Nottingham maternity cases mentioning 38 names of health professionals.

In September, some families complained to NUH that staff were allegedly criticising them with terms like "compo seekers", a situation NUH chief executive May described as "shocking".

In December 2025, in an interim report, Baroness Amos said what she had seen so far "has been much worse" than anticipated but the parent-led Maternity Safety Alliance, which includes families from Nottingham, said the process was "not fit for purpose" due to its wide remit and tight deadline.

In March this year, a new CQC report, based on unannounced inspections carried out the previous May, found NUH "did not always keep women and their babies safe" and renewed its "requires improvement" rating.

Shortly afterwards, the NMC said it had suspended a midwife connected to NUH and confirmed it had 91 open fitness to practise cases related to staff members with links to the trust.

Additionally, Nottinghamshire Police said the scope of its criminal investigation had been expanded to include potential offences committed under the Offences against the Person Act, and the Abortion Act.

It was announced in May the Ockenden review would be published on 24 June and that 850 members of staff had taken part.

Just days later, the GMC said it was reviewing 62 maternity cases in Nottingham hospitals.

In a meeting with families its chief executive, Charlie Massey, apologised for not acting sooner.

He added: "It is clear we should have done things differently."

But campaigners then voiced dismay when Streeting resigned. He was later replaced by James Murray.

The Hawkins said families had invested a lot of time in explaining the complex issues to Streeting, and the prospect of starting again with a new minister was a "real worry".

Their concern was compounded when they were told the findings from the Baroness Amos review would be published on 30 June, just days after the Ockenden review team will make their report public.

Families asked for the Amos report's publication date "to be changed to respect the wellbeing for Nottingham families who have expended so much time and energy fighting to be heard".

"The overlap will result in an intense and demanding period for the families trying to manage the emotional burden of revisiting the most traumatic experience of their life," a statement from the families added.

And, ahead of the Ockenden review being published, a BBC Panorama programme revealed midwives had apparently used offensive terms for some mothers - with one advising "don't be too kind, she'll keep coming back".

Additional reporting by Rob Sissons, East Midlands health correspondent

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