What specific systemic issues allowed for over 500 cases of avoidable harm and death?

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Systemic issues identified as allowing over 500 avoidable harm and deaths at Nottingham University Hospitals Trust

An independent probe found that over 500 mothers and babies suffered potentially avoidable harm or died due to poor care at two Nottingham University Hospitals Trust maternity units, covering cases from 2012 to 2025. It pointed to a “bullying and toxic culture” that was “infected” by a “small minority of powerful leaders”, alongside a “systemic cover-up” and investigations described as being “designed to mislead”. Regulators were also described as prioritising “protecting clinicians” over accountability.
A “bullying and toxic culture” linked to powerful leaders
The report author, senior midwife Donna Ockenden, found a “bullying and toxic culture” across the trust’s two maternity hospitals. She said this culture was “infected” by a “small minority of powerful leaders”, tying leadership influence to how the environment operated over the 13-year period.
A systemic cover-up and investigations “designed to mislead”
The report characterised baby Harriet’s “avoidable death” as being “compounded by a systemic cover-up and investigations designed to mislead”. This framing was used to describe how information and follow-up processes failed families after deaths, including the case of Harriet, who was stillborn in 2016.
Regulators focused on protecting clinicians rather than accountability
In parliament, Health Minister James Murray said regulators had been more concerned with “protecting clinicians” than providing accountability. He also cited broad harms described in the report, including “neglect, incompetence, racism, discrimination, contempt and harassment” experienced by many.
Infant deaths included stillbirths and early deaths tied to specific conditions
The probe reported 94 stillbirths and 62 cases where babies died shortly after birth from conditions including oxygen starvation and hospital-acquired infections. These categories were part of the overall total of at least 156 cases involving baby deaths, and the report’s systemic conclusions were presented alongside these specific clinical outcomes.

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What specific systemic issues allowed for over 500 cases of avoidable harm and death?

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