What systemic failures led to over 500 cases of harm or death at Nottingham hospitals?

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The report points to a toxic culture, systemic cover-ups, and regulatory bias as the core systemic failures behind more than 500 cases of avoidable harm or death at Nottingham University Hospitals Trust.

A damning independent probe into maternity care at two Nottingham University Hospitals Trust units in central England found that over 500 mothers and babies suffered potentially avoidable harm or died due to poor care. The report’s author, senior midwife Donna Ockenden, described a “bullying and toxic culture” at the trust, “infected” by a “small minority of powerful leaders,” and said baby deaths were “compounded by a systemic cover-up and investigations designed to mislead.” It also highlighted neglect, incompetence, racism, discrimination, contempt and harassment, and said regulators focused more on “protecting clinicians” than accountability.
A “bullying and toxic culture” linked to powerful leaders
The probe described “bullying and toxic culture” across the trust’s two maternity hospitals, which it said was “infected” by a small minority of powerful leaders. This cultural framing is presented as a key systemic element behind how concerns were handled, including at the unit where Harriet was stillborn in 2016. In that case, her parents were senior clinicians at the trust and said their concerns were dismissed.
A systemic cover-up and misleading investigations
Ockenden characterised Harriet’s death as “avoidable,” and said it was “compounded by a systemic cover-up and investigations designed to mislead.” The report narrative includes that, even after death, Harriet’s parents said they were not told the truth about what happened. Another example cited involved parents being wrongly told in 2019 to terminate a healthy pregnancy for Wynter Andrews.
Harm patterns tied to neglect, incompetence, and abuse of conduct
The report also pointed to repeated failures in care and treatment of families, with Health Minister James Murray saying many victims faced “neglect, incompetence, racism, discrimination, contempt and harassment.” Murray described the findings in parliament as “chilling,” and linked them to a lack of accountability. The report’s case breakdown included 94 stillbirths and 62 baby deaths shortly after birth from conditions including oxygen starvation and hospital-acquired infections.
Regulators prioritised protecting clinicians over accountability
Murray said regulators had been more concerned with “protecting clinicians” than providing accountability, framing oversight as part of the systemic failure. The probe covered cases spanning 13 years from 2012 to 2025 and involved over 2,500 families, with at least 156 cases involving baby deaths and six mothers also dying at the two units. The report’s account of families describing concerns being ignored—such as the claim that listening to every mother’s concerns would have prevented hundreds of losses—was used to illustrate how systemic issues persisted across time.

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What systemic failures led to over 500 cases of harm or death at Nottingham hospitals?

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