Ockenden review finds toxic culture and avoidable harm at Nottingham hospitals

Hundreds of mothers and babies suffered potentially avoidable harm or death in maternity and neonatal care at Nottingham University Hospitals NHS Trust, and Donna Ockenden’s final report found systemic and sustained failings. The 401-page document, issued by the Department of Health and Social Care and NHS England on Tuesday, also identified a “bullying and toxic culture” across a service spanning Queen’s Medical Centre and City Hospital in Nottingham.

The Independent Maternity Review began in September 2022 and grew into Ockenden’s largest investigation of NHS maternity services. It covered more than 2,500 family cases, involved more than 160 reviewers, and held individual meetings with over 500 families and more than 830 current and former NUH staff. The review closed to new cases on 31 May 2025, had been due to publish in September 2025, and was pushed back to June 2026 as more families joined the process.

Families had pressed for Ockenden to lead the work after losing confidence in earlier arrangements, and the final report lands after years of concern about maternity safety at NUH. The trust has already faced earlier scrutiny, including a police investigation into potentially significant maternity cases. The review examined women’s and families’ experiences of care in Nottingham.

Initial planning had pointed to nearly 1,800 cases, but the final total passed 2,500 as more than 350 families had already contacted the team.

The Nottingham report follows Ockenden’s earlier inquiry into Shrewsbury and Telford Hospital NHS Trust, whose final report was published on 30 March 2022 and formally acknowledged by NHS England on 1 April 2022.