The Nottingham Ockenden report (2026): Key findings and implications for clinical negligence practitioners

The Nottingham Ockenden report (2026): Key findings and implications for clinical negligence practitioners

Marcus Coates-Walker & Robert Mills

THE NOTTINGHAM OCKENDEN REPORT (2026)

Background

On 24 June 2026, Donna Ockenden published her report into maternity and neonatal services at Nottingham University Hospitals NHS Trust (NUH). It is the largest maternity inquiry in NHS history. The review was commissioned in June 2022 by NHS England, replacing an earlier regional review that had lost the confidence of affected families. By the time the review closed in May 2025, nearly 2,500 families had come forward, covering experiences predominantly spanning between 2012 and 2025.

The review owes its origins to a small but determined group of bereaved families, whose courage in demanding accountability made it possible.

Below we seek to set out the key contents of the report and its recommendations, together with exploring the relevance of the report to clinical negligence practitioners.

Scale and methodology

It is worth setting out the report’s grading system at the outset, as this feeds into the assessments of care made. Clinical care was graded using the established CESDI care scoring system:

• Grade 0: Appropriate care in line with best practice.
• Grade 1: Minor concerns. Care could have been improved but different management would have made no difference to the outcome.
• Grade 2: Significant concerns. Suboptimal care in which different management might have made a difference to the outcome.
• Grade 3: Major concerns. Suboptimal care in which different management would reasonably be expected to have made a difference to the outcome.

Across the maternity cohort as a whole, 21% of cases were Grade 2 or 3.

Key findings

Systemic and cultural failure:

1. The overarching conclusion of the report is one of long-standing and deeply embedded systemic failures across multiple areas of maternity and neonatal care. Many of the issues had been known about at NUH since at least 2010. These included: insufficient staffing and funding, the inability of staff to undertake basic (often mandatory) training, a persistent failure to listen to and believe mothers and fathers, and a corresponding failure to investigate and learn from mistakes. At an organisational level, repeated warnings over more than a decade were met with reassurance rather than meaningful action. The findings of the review demonstrate that, over a prolonged period, women, babies and families were failed by a service which too often did not listen, did not learn and did not respond adequately when concerns were raised.
2. The impact of organisational culture was another focus of the report. Ms Ockenden identifies a toxic culture of bullying, driven by a small minority of powerful leaders described as having “infected” the unit. Staff reported significant psychological harm from working in an environment that did not support safe escalation.
3. Related to the organisational culture was Ms Ockenden’s concern about leadership instability. This was identified as a major contributory factor affecting the quality and safety of maternity services at NUH. Between 2017 and 2021 there was sustained turnover in senior maternity leadership positions, including repeated changes in Directors of Midwifery and other senior operational roles. Staff described inconsistent leadership visibility, poor support following incidents and confusion regarding accountability and escalation pathways.
4. The review found evidence that staff shortages and operational pressures affected all areas of the maternity pathway. Staff described routinely working beyond safe capacity, inability to complete mandatory training and insufficient opportunity for reflection, supervision and learning. Workforce instability, high sickness absence and reliance on temporary staffing contributed to fragmented care and reduced continuity for women and families.

Governance and leadership failure:

1. The review also identified long-standing and systemic failures in clinical governance. Multiple internal and external reviews over more than a decade. It repeatedly identified concerns relating to: incident reporting, investigation quality, harm grading, duty of candour, leadership oversight and organisational learning. Despite these repeated warnings, improvements were often incomplete, delayed or unsustained.
2. The review identified evidence of poor governance structures, inadequate Board oversight and a disconnect between assurances provided to Trust leadership and the lived experiences of families and front line staff. External reviews, regulatory findings and commissioner concerns repeatedly highlighted weaknesses in maternity governance, culture and safety processes over many years.
3. A recurring finding throughout the review was the failure to learn effectively from incidents. This is an all too familiar story to clinical negligence practitioners on both the Claimant and Defendant sides. Families were frequently told that lessons would be learned following harm or bereavement, yet similar incidents recurred repeatedly over many years. Investigation processes were often inconsistent, delayed and insufficiently multidisciplinary.
4. One particular concern was that the review found that clinical records on numerous cases had been intentionally deleted. This matter has been referred to the police and forms part of the ongoing criminal investigation.

Inequalities in care: Inequality in care is a wider theme across maternity enquiries. For example, 35% of cases in the review came from the most deprived areas in England (Index of Multiple Deprivation (IMD) 1 and 2), with an odds ratio of 1:1.75 for families living in poverty. The sad reality is that maternal deaths are at a 20-year high. Women living in the most deprived areas and black women remain at greater risk of death. The report calls for care that is genuinely equitable across socioeconomic and ethnic groups.

Failure to listen to women: This is a dominant theme in the review and one which has been seen again and again in independent assessments of maternity care. The review identified a systemic failure to listen to women. Women described their concerns being dismissed as anxiety at telephone triage, being denied timely reassessment despite deteriorating symptoms, and having pain and distress disregarded during labour. Women from ethnic minority backgrounds and those for whom English was not their first language were found to be particularly vulnerable.

Failure across the entire maternity pathway: Clinical negligence practitioners may wish to pay particular attention to the specific deficiencies in care identified, which are likely to be fertile ground for future claims. The report identifies specific and recurring clinical failures at every stage of the maternity pathway. These include:

1. Antenatal care: Fragmented antenatal care, an absence of continuity of midwife, failure to identify and monitor pregnancies at risk of fetal growth restriction, failure to respond to reduced fetal movements (a dominant recurring theme, with multiple stillbirths), language failures with a failure to provide interpreters, poor management of induction, and failure to plot symphysis-fundal height measurements correctly.
2. Intrapartum care: Dismissive telephone triage, inadequate pain relief, failure to obtain informed consent before interventions, failure in fetal heart rate monitoring, unsafe CTG interpretation, failure to recognise fetal compromise and escalate to senior clinicians, poor management of the third stage of labour and delays in recognising and escalating postpartum haemorrhage (PPH) and major obstetric haemorrhage (MOH), inappropriate and unsafe use of oxytocin (commenced or continued in the presence of tachysystole, hyperstimulation or pathological CTG, which caused multiple HIE cases and stillbirths).
3. Neonatal care: Delays in emergency neonatal resuscitation, delayed escalation to senior clinicians, hospital-acquired infections in overcrowded environments, and failures in airway management. The neonatal service operated for many years under severe capacity pressure across two sites.
4. Maternal deaths: Failures in escalation, failure to monitor for maternal hypertension, failures in VTE risk assessment and anti-coagulation, inconsistent multidisciplinary working, and communication failures.

Recommendations

The report sets out eight categories of Immediate and Essential Actions (IEAs) applicable across all maternity services in England:

• Listening to women and families, including a mandatory “Listen to the Woman” assessment field in triage documentation.
• Workforce planning and safe staffing, governed by a nationally agreed evidence-based planning methodology reflecting maternal complexity (not simply birth rates).
• Training and multi-professional learning.
• Risk assessment throughout pregnancy.
• Incident investigation with active family involvement.
• Governance and Board accountability.
• Culture, teamwork and psychological safety for staff.
• Appropriate support for families following maternal or neonatal death, including post-death and bereavement care.

The overarching principle underpinning all IEAs is the activation of Martha’s Rule: women, families and staff must be able to seek an urgent additional clinical review through clear, accessible and responsive routes (in both hospital and community settings) whenever there is ongoing concern about a patient’s condition.

Significance for clinical negligence practitioners

An increase in potential claims? The report is likely to add to the volume of clinical negligence claims relating to birth injuries. Individual written feedback from the review team will be provided to all families in the cohort, with those receiving Grade 2 or Grade 3 gradings offered meetings with the review team. This process will likely act as the trigger point for many claims from these cases alone. Practitioners should note that the care-grading system measures clinical care standards against the CESDI framework. That is not a determination of legal liability. The Bolam/Bolitho framework remains essential and independent expert evidence on breach and causation will still be required.

The cost of negligent maternity care: According to the NHS Resolution Annual Report 2024/25, 51% (£2.5 billion) of the total NHS clinical negligence cost of harm (£4.9 billion) relates to maternity — an increase from 49% the previous year. Clinical negligence is now costing the NHS almost as much in legal compensation as it spends on delivering maternity care itself. NHS Resolution settled maternity clinical negligence claims totalling £1.3 billion in 2024/25, representing 42% of the total value of all notified clinical negligence claims. This could fuel campaigns for reform of the clinical negligence process in the UK, including calls for a so-called “no fault” system. The Ockenden Report shows that the area in greatest need of reform, however, is the provision of maternity care itself. The most efficient way to get clinical negligence litigation costs down is to learn from mistakes and prevent birth injuries.

HIE and cerebral palsy:

1. The report’s clinical data will be of direct relevance to practitioners advising on quantum in high-value cases. Of the hypoxic-ischaemic encephalopathy (HIE) cases reviewed, 50.3% of maternal cases the worse grading of significant or major concern (grade 2 or 3). These categories generate the most complex and highest-value claims and are likely to require the most intensely contested expert evidence on breach and causation.
2. The review found that NUH had appropriate national guidance and structured assessment processes for therapeutic hypothermia in babies with HIE, and that in most cases care was good and in line with national standards. However, recurring concerns were identified regarding delays and deviations in cooling practice. Passive cooling was routinely continued within the neonatal intensive care unit beyond what national guidance recommended, potentially impairing neurological assessment and delaying active cooling. Several babies experienced delayed achievement of target cooling temperatures, including cases where active cooling commenced after the recommended six-hour treatment window. Additional concerns included delayed cerebral function monitoring and one case where coagulation abnormalities during cooling may have contributed to worsening intracranial haemorrhage. Finally, the review also identified cases where prolonged untreated hypoglycaemia may have compounded hypoxic brain injury. Overall, while most HIE management was appropriate, the review concluded that inconsistent adherence to evidence- based cooling pathways created avoidable risks of further neurological injury in a small number of babies.

Duty of candour, gaslighting and limitation:

1. The report identifies what it characterises as a “culture of compounding harm”, involving active denial, gaslighting and victim-blaming of families who sought honest explanations. This finding has direct implications for limitation. Where a Trust has deliberately misled a claimant family about the true cause of harm, the date of knowledge under section 14 of the Limitation Act 1980 may be significantly delayed. Practitioners acting for claimants should examine carefully when each family first received (or could reasonably have obtained) an honest account of what went wrong, and whether any representations made by the Trust during that period amount to concealment for limitation purposes.
2. The Duty of Candour under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires NHS Trusts to be open and honest when things go wrong. The report documents sustained non-compliance with that duty across many years. This is a matter relevant both to the underlying merits of individual claims and, in appropriate cases, to applications in respect of aggravated damages.

Intentional destruction of records: Of particular significance is the finding that clinical records were deliberately deleted. The report notes that NUH prematurely destroyed the medical records of two women who died, in breach of the NHS Records Management Code of Practice requirement for a minimum 25-year retention period for maternity records. In the civil context, deliberate or negligent destruction of records may give rise to adverse inferences and is relevant to specific disclosure applications and requests for further information. Practitioners should request confirmation of the records preservation position, audit trails and any available metadata from the Trust’s digital patient record systems at the earliest opportunity (i.e. pre-action).

The broader national context:

1. This report does not stand alone. It follows Donna Ockenden’s earlier report into maternity services at Shrewsbury and Telford NHS Trust (2022), the East Kent Kirkup Report (2022), and the Morecambe Bay Investigation (2015). A pattern is now unmistakable across multiple NHS Trusts. The same failures of culture, staffing, governance and listening to women. The Secretary of State has subsequently appointed Donna Ockenden to lead a further review of maternity services at Leeds Teaching Hospitals NHS Trust.
2. The IEAs published in this report place every maternity service provider in England on notice that future failures to implement the required standards will face significantly more difficult causation arguments in subsequent litigation.
3. In parallel with the civil litigation landscape, practitioners should also be alert to Operation Perth. This is an ongoing police investigation into NUH, which is looking at whether the Trust committed any criminal offences, including gross negligence manslaughter and serious assaults under the Offences Against the Person Act.
4. The Trust has already pleaded guilty in February 2025 to six charges brought by the CQC relating to failures in care involving three mothers and their babies, resulting in a total financial penalty of £1,667,944.
5. The coexistence of a live criminal investigation and a high volume of civil claims requires careful management. Practitioners should be alert to how admissions, disclosure and the timing of pre-action correspondence may interact across proceedings in both jurisdictions.

Conclusion

The Nottingham Ockenden Report represents the most extensive maternity inquiry ever conducted within the NHS. Its findings are damning: long-foreseeable, systemic failures of leadership, governance, culture and clinical practice led to the deaths and serious injury of babies and mothers for more than a decade, whilst warnings went unheeded and families who sought honest explanations were repeatedly failed. For clinical negligence practitioners, the report opens a substantial and complex new caseload. The grading system, the findings on failing to listen to families, the record-destruction issue and the parallel criminal investigation together create distinctive issues to an already complex litigation landscape.