The publication of the final Ockenden Report on 24 June 2026 marks a significant moment for maternity services across England. As the largest maternity review in NHS history, the investigation examined more than 2,500 family cases relating to care provided by Nottingham University Hospitals NHS Trust and has revealed a pattern of serious and, in many cases, avoidable failings which resulted in devastating consequences for mothers, babies and their families.

Led by independent maternity reviewer Donna Ockenden, the inquiry considered cases involving maternal deaths, stillbirths, neonatal deaths and birth injuries. The report found repeated failures in clinical care, alongside missed opportunities to identify risks, respond appropriately to concerns and learn from previous incidents.

At the heart of the report are the experiences of families whose concerns were ignored or dismissed at critical moments. One particularly distressing account involved a mother who reported feeling pain during a caesarean section despite raising concerns that her anaesthetic had not taken effect. Other evidence presented to the review highlighted instances of traumatic deliveries, failures in fetal monitoring, delays in escalation of care and shortcomings in postnatal management. In many cases, independent experts concluded that different clinical decisions could have altered the outcome.

Beyond individual episodes of poor care, the report identified wider organisational issues that allowed unsafe practices to persist over a prolonged period. A culture described as defensive, and, at times, toxic was found to have prevented both staff and families from raising concerns effectively. The review concluded that failures in leadership, governance and accountability contributed to an environment where opportunities for learning were repeatedly missed and patient safety was compromised.

The findings also highlighted continuing inequalities within maternity care. The report drew attention to longstanding national concerns regarding outcomes for women from ethnic minority backgrounds and those living in areas of socioeconomic deprivation, reinforcing the need for targeted action to address disparities in maternal healthcare.

Speaking following publication of the report, Donna Ockenden described the experiences shared by families as being characterised by three recurring themes; a failure to listen, a failure to investigate and a failure to learn. Many campaigners and affected families have since called for a wider statutory public inquiry to examine whether similar shortcomings exist elsewhere within NHS maternity services.

The report sets out a series of recommendations aimed at improving standards of maternity care nationally. These include: –

• Greater consistency in the management of obstetric emergencies.
• Stronger leadership, governance and accountability arrangements.
• Improved engagement with families throughout investigations and reviews.
• Enhanced psychological support for both families and healthcare professionals.
• Better communication and implementation of learning from adverse incidents.
• Improvements to bereavement care and post-death processes to ensure families are treated with dignity and compassion.

The findings arrive against a backdrop of increasing concern regarding maternity safety across the NHS. Maternity-related claims continue to represent a substantial proportion of the overall cost of clinical negligence litigation, with birth injury claims accounting for some of the highest-value cases handled by NHS Resolution.

For many families, however, the significance of the Ockenden Report goes far beyond statistics. It represents long-overdue recognition of experiences that were, for years, overlooked or challenged. The hope now is that the lessons identified in Nottingham will lead to meaningful and lasting improvements in maternity care across the country.

At Williamsons Solicitors, we understand the profound impact that negligent maternity care can have on parents and families. Our Clinical Negligence team has extensive experience assisting clients affected by stillbirth, neonatal injury, cerebral palsy, delayed diagnosis and failures in antenatal, labour and postnatal care. If you have concerns regarding the maternity treatment, you or a loved one received, our specialist team is here to provide advice and support.