Nottingham Maternity and Neonatal Services
House of Lords · Lords Chamber · 29 Jun 2026 · 45 speeches · Official Report
Statement
The following Statement was made in the House of Commons on Wednesday 24 June.
“With permission, Madam Deputy Speaker, I will make a Statement on the independent review of maternity services at Nottingham University Hospitals NHS Trust.
Donna Ockenden’s review is the largest into a maternity service in the history of the NHS. The nature and sheer scale of the failings it exposes are horrific. It uncovers dangerously and tragically deficient care at almost every turn. Its findings and conclusions are chilling.
The report covers 13 years, including accounts from 838 members of staff and, crucially, the experiences of 2,536 affected families. I met a small number of those affected families last week, and I felt numb after hearing the depth of their pain. I felt even more numb when I considered how many families not in the room went through such trauma too, and the forgotten children who survived but live every day with the consequences of maternity care failings.
I felt devastated that so many women and babies, as well as their fathers and other family members, had suffered injury, death and lasting trauma while under the care of the NHS. Now having met the families, and having seen the report, I feel appalled by the neglect, incompetence, racism, discrimination, contempt and harassment that so many suffered. I feel heartbroken to know that, so many times, when they tried to raise the alarm about their care, they were ignored, sneered at, disbelieved, blamed and lied to. How on earth could this have happened? There is no single answer, but Donna Ockenden shines a light on what was going on.
First and foremost, women were not listened to. Donna Ockenden says that the staff shortages and lack of training in Nottingham were among the worst she has ever come across. Bullying by doctors and senior midwives was rife, which meant that staff who tried to speak up were intimidated and ridiculed. There was a culture of cover-up at the highest levels of the trust, and there were ineffective and inadequate responses from regulators.
Perhaps most damning of all, for years the trust ignored evidence of clinical and cultural flaws in both internal and external reviews that it had itself ordered. When I met Donna Ockenden last week, she told me that those inquiries were ‘diligent’ and of ‘good quality’ but that they were effectively swept under the carpet by the board. That refusal to act is unforgivable.
Donna Ockenden and her team deserve huge credit for their forensic and compassionate approach, as does my honourable friend the Member for Sherwood Forest (Michelle Welsh), herself a harmed mother, as well as Members for neighbouring constituencies who have walked side by side with their constituents through years of anguish and struggle.
However, the driving force behind the review has been the affected families themselves. They have demonstrated more patience, more courage and more tenacity than one might imagine is possible from those dealing with broken hearts that will never mend. Though each of their experiences is unique, one feature is common: at the very moment when they were at their most vulnerable, they placed themselves and the lives of their unborn babies in the hands of the NHS-and the NHS failed them catastrophically.
To all those who have suffered so appallingly, I say today, on behalf of the NHS: I am sorry. I am sorry not just for the failures, or the heartless and undignified treatment, but because your cries of concern went unheard for too long-and so the Government will act. We will act by taking immediate steps, including to expand Martha’s rule to all maternity and neonatal settings so that parents can demand a second opinion if they feel their concerns are being ignored.
I know that some people may want me to accept all the review’s recommendations today, but in the past too many recommendations have been accepted and then have sat on a shelf gathering dust, and we have seen more deaths and more suffering. I do not want to let down the families I met in Nottingham, or bereaved parents anywhere else in the country. I want to use the National Maternity and Neonatal Taskforce, which I chair, to create a comprehensive action plan to be published by the end of this year that will address all the national-level recommendations from this review and others. I am confident that work will be welcomed by all those midwives, obstetricians, paediatricians and other healthcare workers who strive every day to make sure that babies are born safely and that women receive outstanding levels of care.
It is clear that, in case after case, families felt that regulators, including the General Medical Council, the Nursing and Midwifery Council and the Care Quality Commission, were more concerned with protecting clinicians than with providing accountability. That is damning and that is wrong. As one grieving mother told me:
‘They put the fox in charge of the hen house’.
Clinicians and trust leaders must know that their behaviour will be properly scrutinised and that their actions will have consequences. We must meet the test of the Nottingham victim who told me last week that ‘accountability drives action’.
We are making changes to the CQC, one of which is to extend the cut-off period to initiate proceedings from three to five years so there is more time for families to bring cases. I will also call in the chair and chief executive of the GMC to hear directly their account of the failures at NUH. Let me be clear: if their response falls short, things will change at the GMC.
From speaking to families in Nottingham, I know that there is real and understandable anger that some leaders and clinicians at the centre of this review were able to avoid giving evidence. Today, I make a commitment that, when passed, we will use the Hillsborough law’s duty of candour to ensure that witnesses in upcoming reviews of maternity service failures, including those in Leeds and Sussex, can be forced to provide evidence. That change will make sure no one is able to refuse to co-operate in the search for accountability and justice ever again.
There is so much in the stories of the families in Nottingham that is shocking and heartbreaking, but the way the bodies of their loved ones were handled by hospital mortuary services revealed a level of disrespect and a lack of humanity that-I will be honest-left me utterly aghast. The details are disturbing, but they need to be heard to understand the gravity of what families were confronted with: deceased babies referred to as a ‘specimen’ or ‘sample’; a baby placed into a mortuary space already occupied by an unknown and unrelated adult; a baby disposed of as clinical waste against the express wishes of their parents; and a baby kept in a domestic fridge in a bereavement room. The emotional and psychological effect of those dehumanising failures was to layer the most profound disrespect on the most unbearable distress. There is also evidence that the trust actively decided not to report failings in mortuary care to families.
As honourable Members will know, there is an active police investigation and arrests have been made, which limits what I can say. As a start, however, I have asked NHS England to write to trusts to make sure these appalling experiences are not happening elsewhere in the NHS. I confirm today that the Human Tissue Authority will require all mortuaries to review internal records going back 10 years to ensure all incidents have been logged and reported. I have instructed them to report the findings directly to me by 16 October.
When I met the Nottingham families last week, they also raised with me the issue around what are known as secondary victims. In maternity settings, fathers, partners and others are actively encouraged to be present to support mothers through labour and delivery. However, the law does not allow them to bring their own claims for the psychiatric illness suffered as a direct result of witnessing their partner or baby suffer injury or die. I have therefore asked David Lock KC to work with my officials to consider that important issue as part of his wider work on clinical negligence.
Donna Ockenden acknowledges that NUH has not waited for her findings to be published to start making improvements. I will speak to the chief executive next week to interrogate the trust’s response and make sure there is a proper plan in place for implementing the recommendations speedily and effectively. But there is a long road ahead before NUH fully addresses all the issues and before it can possibly regain the full trust and confidence of the communities it serves.
I close where I began: with the families. Nothing can make up for what they have gone through, but this report is a tribute to their resilience and tenacity. I say to them directly: you had to drive this for so long, but you are no longer driving this alone. We are with you and we will not stop until you have the accountability and the justice you deserve. I commend this Statement to the House”.
My Lords, I thank the Minister for the opportunity to ask questions on this Statement on the report, which raises many troubling issues. I add my thanks to Donna Ockenden and her team for their extraordinary work in conducting what has been the largest review of maternity services in the history of our NHS. Our thoughts are with the thousands of mothers, babies, fathers, partners and families whose experience lies behind this report. It is only because of their courage and determination that these failures have finally been brought to light. When, in the past, I have spoken to families who feel that they have lost a relative or friend due to medical negligence, they often say to me that they are reluctant to pursue justice, since it adds to their grief. They also point out that they often face hostility for raising concerns, as they are seen to be criticising the NHS. This is a terrible indictment. No organisation, including the NHS-perhaps especially the NHS-should be above criticism. The findings expose years of failures in leadership, governance and culture, not just a few isolated cases of clinical failure. Women were not listened to, families were dismissed, and staff were unable to raise concerns in an environment where bullying and intimidation were embedded. Most disturbing of all, the report noted that evidence of these failings already existed, yet action was repeatedly delayed or avoided. However, we on these Benches wish to be constructive in our response, since...
My Lords, the Statement before us today from the Secretary of State in the other place is distressing reading, as is the report by Donna Ockenden. This review shocks us all to the core and must shake the Government into real action at every level of our health service and its regulation. Staff concerns were dismissed, a board did nothing and regulators failed in their duties. There was a simple refusal to listen to women and their families, causing such loss, trauma, negligence and damage, alongside bullying, organisational failures and the horrendous misplacing of bodies. Words just cannot express this horror. What brave and resilient families to keep fighting for justice; I thank them all. I heard the deeply moving testimony at the press conference last week about the mental health legacy for bereaved parents. One explained how she had lost all trust in the NHS and had the constant, triggering experience of having to engage in her daily life with the organisation she holds responsible for the loss of her baby. It is hard to imagine. This review, and the upcoming wider review from the noble Baroness, Lady Amos, must draw the line. This has to stop. Mothers, babies, children and families must have confidence that they will be provided with first-class maternity services, wherever they live in our country. There must be quality services that meet their needs whatever their age or background, with respect and dignity at the heart. I welcome the taskforce, chaired by the...
My Lords, we find ourselves deeply affected, as we have heard from both Front Benches. I am grateful for the tone and for the acknowledgement of the experiences of bereaved and harmed families who are at the absolute centre of this. The noble Baroness, Lady Pidgeon, said that she could not get her head around many of these things; I am sure we are all in agreement on that. I share the views of both Front Benches. I am grateful for the support for action. I absolutely agree with the noble Lord, Lord Kamall, that there is only one test: action. As the noble Baroness, Lady Pidgeon, said, it is also about confidence and step change. We all want to get this right. It is not recent; it is not isolated-as both Front Benches identified. It should not be the case that those who are bereaved and harmed have had to show such courage and determination. This is an impossible circumstance that people are in. The noble Lord, Lord Kamall, said that people understandably often do not wish to add to their distress. The fact is that women, babies and families have all been terribly let down, not as a one-off but by a system-a system that failed to listen, failed to be transparent and, to make it even worse, failed to provide the truth when things went wrong. We are looking at 13 years, since 2012. This is a sustained approach that was totally unacceptable. On behalf of the Government, I want to say how deeply sorry I am, and the Government are, for what every family has suffered and for those...
This is the most appalling thing that has happened. I have great respect for the Minister, and I thank her for letting us know about some of the action plans going ahead. What has gone wrong with a profession where the professionals have seemingly no empathy for those they are caring for? Is this about society? Have we given up putting others first? Have we become a society where we do not listen and do not treat each person as an individual with needs individual to them? That is what I was taught when I was given my nursing training. Is that being taught now? Have we forgotten how we behave towards individuals when they are asking for help? Do we not listen and do everything in our power to make them feel better? Government cannot do everything; it has to be society that can, in some way, teach people in these very important roles how they treat the human beings in front of them.
I certainly agree. Every woman, in the case of maternity services, deserves safe and compassionate maternity care. That is why we are so determined to drive urgent improvements in maternity services. It is worth noting that this review-the largest ever of its kind, as the noble Lord, Lord Kamall, said-considered the experience of more than 2,500 families and 830 staff. I think it is important that your Lordships’ House also remembers how many staff have found themselves in situations they would never have wanted to be in. I am sure that the noble Baroness, like me, pays great tribute to the many NHS staff who are in the majority in doing their work in a compassionate way-as the noble Baroness has experienced. I cannot comment on whether it is specific to society but, from Donna Ockenden’s conclusions, there was something deeply wrong here. Whether it was not listening, culture or racism and discrimination towards women, families and staff, and between staff, we cannot have it.
My Lords, to continue this theme, the report describes a bullying and toxic culture, with junior midwives not being sufficiently supported when dealing with complex cases. It was a culture that did not allow them to refer such cases up the chain. There was a constant turnover in senior midwifery leadership and those they appointed were not given proper induction, mentoring or even guidance about their roles. In the work that the Minister is taking forward with the Secretary of State, will there be a concerted national programme of training and development for senior midwives so that there is a real opportunity to try to grip these issues?
My noble friend’s analysis is quite right. One of the reasons we are developing an anti-discrimination programme is that cultural change across maternity and neonatal services is much needed. I use that as one example; all NHS trusts are to have completed that programme by 2027, and that is already under way. I found it absolutely shocking that so many senior people at Nottingham did not give evidence to Donna Ockenden’s investigation. That is why, once the Hillsborough law Bill receives Royal Assent, we will extend the duty of candour to the Leeds and Sussex reviews so that the chair, Donna Ockenden, will have the powers to find the truth from organisations and staff. On the earlier point, it is quite shocking and totally unacceptable that they refused to participate.
The Ockenden report does a great job in looking at the problems in one specific trust. However, the problems go much deeper, as the Minister has said. It is cultural, and one of the cultural problems appears to be that there is a complete split between a contingent of midwives and the rest of the medical profession about medical intervention. Until that is tackled, I cannot believe that we are going to get to the root of the problem. Will the Minister commit that the taskforce will delve into that difficult issue? It is cultural, but it is a very deep difference of opinion that goes back to the noble Baroness’s question about what has changed. That is part of what has changed.
The key is to bring together the recommendations from Donna Ockenden’s report with the independent report that we established, chaired by my noble friend Lady Amos, which will report on Tuesday, as well as the reviews from before. I do not think we necessarily need a description of the problem but, to the noble Baroness’s point, we do need action to challenge and monitor this. Transparency and accountability will also be our friends, which in Nottingham they were not.
My Lords, as we know, this horrific failure is not confined to Nottingham University Hospitals NHS Trust. A number of other NHS trusts are being investigated, and I suspect it goes much further. Neither is this a problem of just the last 13 years; it goes back decades. Forty years ago, one of my twin sons died at birth, a combination of bad decisions, inadequate systems and negligence. It was similarly impossible to get answers, with the name of the midwife withheld and the notes disappearing, including the only photo, and no one held accountable. The damage to families from this type of behaviour is unquantifiable. How is the Minister going to change this endemic culture of cover-up in the NHS and ensure that systems are put in place so that when even one baby is put at risk, is damaged or dies, the situation is properly examined so that it cannot happen again?
I am so very sorry to hear of the noble Baroness’s experience; I am grateful to her for sharing it with your Lordships’ House. I am sure we all offer our condolences and understanding as far as we can to support her and her family, and I say how sorry I am for her loss. The noble Baroness is right to talk about cover-up. That did happen in this case and has also been identified through other reviews. Certainly, as Donna Ockenden conducts reviews into Leeds and Sussex, we will be able to find out what happened there. But we are not waiting, and I assure the noble Baroness of that. It is worth speaking about the role of the regulators, because it has come up not by using the word itself but by how account is kept. The Secretary of State is meeting with the GMC-which we currently have a three-month consultation on reforming-because he wants to hear its personal account for failings in care. The Nursing and Midwifery Council has been undergoing a widespread programme of reorganisation and change under new leadership, which, again, is much needed. I assure the noble Baroness that, as part of the taskforce, we are looking at all parts of the health system where things go wrong, including how accountability is established, because we should be avoiding that harm where it is avoidable.
My Lords, I welcome the report and thank my noble friend the Minister for all the work she is doing with the Secretary of State to support and to implement recommendations. Our thoughts are with the families affected. The report has yet again shown the racial bias in care, which is harming mothers and babies. I request that my noble friend the Minister ensures that cultural competency training is integrated in medical school and in midwives’ training, so that they are qualified after receiving that training and it is not left for later.
It is absolutely crucial, as my noble friend says, that the training should reflect the needs of the care that will be given. That is something that I know the taskforce will look at very closely. Donna Ockenden’s report offers insight and recommendations on workforce and training. The noble Baroness, Lady Amos, may also do so. I mentioned the anti-discrimination programme, but I should also say, on inequalities, that we have launched a maternal care bundle on what the best practice is for clinical conditions that are the leading causes of death for women from Black and Asian backgrounds. As I say, the numbers reflect a great inequality which cannot be allowed to continue.
My Lords, building on the Minister’s comments on the maternal care bundle, which was introduced because Black women are 2.3 times more likely to die in childbirth, this report also confirms that, in Nottingham and Nottinghamshire, infant mortality rates were significantly higher for Black and Asian women. In the report, a full dataset is not given of women of ethnicity. Can she also reflect on the recommendations from the Preterm Birth Select Committee report that we need more nuanced recommendations in this regard, and more work on causality? It is not clear, from what I have read in the report, why there is a 2.3 times greater likelihood that these women die; we need more work on that as well.
The noble Baroness is right to refer to the report undertaken by the Lords committee, which I was pleased to be invited to appear before. It is true that there is a complexity. Outcomes also vary between trusts. There are a lot of potential reasons, but “potential” is not good enough. In 2023, the number of stillbirths in the most deprived areas remained much higher than in the least deprived. In all the ways that noble Lords, including the noble Baroness, have mentioned, there are deep inequalities. NHS England has published an inequalities dashboard. That is important because it supports the identification of areas where populations face the greatest disparity, so that interventions can be appropriate for them and there can be more equitable support. We will certainly look very carefully at the differences and the inequalities, because that will be a real driver for change.
My Lords, I thank my noble friend the Minister and the Secretary of State for their hard work, shining a light on the inadequacies in maternity services in this country. My question is more general. The Minister referred to the coming Hillsborough law-one would hope in the next Session-which will be vital to accountability and driving candour across reviews into areas of both public and private failure. I respectfully ask, if the Minister cannot update me on progress being made on an oversight mechanism, whether the relevant Cabinet Office Minister might write to me to provide an update on progress. I am afraid that without the addition of an oversight mechanism, whether through a powerful public committee set up within Parliament or an independent body, we will once again return to terrible stories, whether in maternity, construction or other aspects of care.
I will be pleased to raise that with my ministerial colleague in the Cabinet Office. I agree that an oversight mechanism is very important. On the Bill-which will, of course, become an Act-it is key to note that it will establish a new duty of candour and assistance at inquiries, inquests and other investigations. To the point that we are discussing here, the Bill will also allow for that duty of candour to be applied to health investigations by regulation. That is crucial, and it is by using that power that we will ensure that the Leeds and Sussex reviews, which are live, are included through secondary legislation.
My Lords, I align myself with the comments that have been made by the noble Lord, Lord Kamall, and the noble Baroness, Lady Pidgeon. This a totally devastating outcome. I pay tribute to the families that have been affected in this way. I am just absolutely disturbed by the quality of the governance at the trust. I am shocked. I have chaired a number of trusts. To not put patient safety first and to not have the data available to make that judgment is absolutely appalling. Therefore, in terms of accountability, will the Minister assure me that the chief executive, the chair or, indeed, any members of the board who have been given honours as a result of their service to their trust are stripped of them? It is not an honour; it is absolutely devastating, and there has been a lack of duty in what they have achieved.
I completely understand the noble Baroness’s point. I am grateful for her sensitivity on this subject. I do not feel qualified to comment on honours and their removal, but I will raise it with the appropriate ministerial colleague to say that this is a view-exactly as the noble Baroness said. I know that she is not alone in feeling that.
My Lords, this is an appalling case, but some of the themes in it are common to other scandals, including the Post Office scandal: people being ignored, people not knowing how to complain and the system basically coming together to protect itself rather than representing and identifying failings. I accept that the Hillsborough Bill will be a step forward, but we also need a cultural change, and I stress that one of the issues is the GMC. Self-regulation has to go. It is about time that doctors were held to account, because anyone who has tried to complain about a medical situation through the GMC finds that it is labyrinthine and slow, and does not put the patient at the centre.
My noble friend is right to draw comparisons and, as I said earlier, I certainly agree on the point about culture that is made very clearly in the report from Donna Ockenden. I will be looking very closely at that also in the recommendations of my noble friend Lady Amos. As I said earlier, we have sought to make change. I do also think that accountability and transparency are absolutely key. It is one thing to seek to make change, but another for people to feel confident and to know it has happened.
I am grateful to the noble Baroness for her eloquent and moving statement and her commitment to taking action on this. The noble Baroness said that the workforce planning recommendations from the Ockenden review and potentially also from the Amos review will be picked up in the maternity taskforce action plan, due at the end of the year. Can she tell us how that will fit with the upcoming wider NHS 10-year workforce plan? Will the wider 10-year workforce plan also look at the staffing and training needed for safer maternity services, and can she confirm when it will be published?
We are soon expecting the 10-year workforce plan. In its considerations, it will address patient safety, because that is one of the requirements when thinking about workforce. But the really close look in the way the noble Baroness seeks will be through the plan which the taskforce is overseeing, having received the recommendations. It is the case that maternity services, for a whole range of reasons, including the absolutely shocking experiences that we have all referred to, have suffered in some areas because of a lack of safety, a lack of listening, and the wrong kind of culture and leadership-the list goes on. I know that noble Lords will have looked at the report and I would want to ensure that maternity services have their particular focus, in order that what I believe will be a credible plan by the end of the year will take account of the very points that the noble Baroness rightly makes.