Mark Hughes

The Independent review of maternity services at Nottingham University Hospitals NHS Trust was commissioned in June 2022 and looks at the provision of maternity and neonatal care at the Trust between 2012 and 2025. More than 2,500 families and over 800 staff have contributed to this review. It concluded that there were potentially avoidable outcomes relating to 444 maternity cases examined up to May 2025, alongside 76 neonatal cases. Key issues identified in this report include insufficient staffing and funding across perinatal care settings; the inability of staff to undertake even basic (often, mandatory) training; a persistent failure to listen to and believe mothers and fathers; and a corresponding failure to investigate, and therefore learn from, mistakes. The Review identifies 18 immediate and essential actions to improve care and safety in maternity services across England, which are summarised below: 1. Strengthening women-centred communication and informed choice All women must be provided with clear, consistent and accessible information throughout pregnancy to support informed decision-making. This should include information about labour and birth, pain relief options in labour, anaesthetic care for operative delivery, and the potential benefits and risks of different interventions. 2. Support a nationally agreed perinatal workforce planning methodology as a critical enabler of perinatal improvement at pace and scale Investment should be made in the development and implementation of a robust, evidence-based workforce planning tool across perinatal services. The tool should move beyond birth rates alone to reflect population complexity, including factors such as maternal age, co-morbidities, deprivation, acuity and service configuration. 3. National immediate and essential actions labour ward coordinator (LWC) role Implement a nationally recognised LWC programme for all Band 7 LWC midwives undertaking the LWC role. Provide structured opportunities and support to achieve the competencies and standards outlined across the six domains of the national LWC Framework. Introduce 360-degree feedback for all LWCs to support reflection, performance development and understanding of the impact of behaviour on the multidisciplinary team. 4. All trusts must support training for midwives in the use of speculum examination All Trusts must ensure that midwives are supported to achieve local training competencies to perform speculum examinations for women at any gestation of pregnancy, with clear escalation pathways for women in pre-term labour or those requiring immediate ongoing care. 5. Enhanced maternal care All staff caring for pregnant women must receive regular, structured multidisciplinary training to ensure timely recognition and effective management of the deteriorating woman. Training must equip midwives, obstetricians, anaesthetists, critical care teams and outreach services with the skills, knowledge and confidence to deliver safe, high-quality enhanced maternal care. National education programmes must cover key areas of maternal care and include the recognition and management of lesser-known but clinically important conditions, such as maternal ketosis, to ensure consistent, safe and excellent care across all maternity services. 6. Delivering safe, personalised and equitable maternity care through early risk recognition, coordinated care and responsive services All Trusts must ensure women receive the appropriate ‘safety-netting’ within their care, enabling them to access services and treatments, including the consideration of reducing barriers to enable to the provision of safe maternity care. 7. National standard for standardisation and recording of fetal growth risk assessment There must be standardisation of fetal growth risk assessment, management and audit across RCOG, SBLCB and NICE guidance, with clear concise recommendations on the choice of pathways and charts to ensure consistency of the approach to the reduction in stillbirth. All practitioners performing ultrasound growth scans should have training to undertake and report examinations to meet the standardised methods used in the recommended charts. 8. There must be a national standard and documentation for maternity triage and record keeping in maternity care provision Trusts must develop a robust method of training for midwives providing triage care. This must include minimum competency standards for telephone risk assessment, agreed pathways for mandatory attendance for review and a holistic review of physical, mental and social wellbeing assessment. Suppliers of Electronic Patient Record (EPR) systems must ensure there is a standardised national maternity handover tool that addresses interoperability gaps between Trust systems. All Trusts must implement the standardised national Maternity Early Warning System (MEWS) with clearly defined escalation pathways wherever they are being cared for. 9. Support the development and implementation of a structured assessment framework for the latent phase of labour, ensuring clarity when the ‘latent phase of labour’ becomes abnormal requiring escalation Develop and implement a structured assessment framework for the latent phase of labour, incorporating maternal and fetal wellbeing, the woman’s preferences and narrative, social circumstances, potential barriers to accessing care (e.g. language or socioeconomic factors), time of day, and distance from the unit when determining the appropriateness of admission. 10. All Trusts must define criteria for the safe use of telephone postnatal follow-up, indicating when telephone follow-up is acceptable or when face-to-face follow-up is mandatory The first risk assessment for this should be documented in the woman’s notes in the antenatal period (by 34 weeks gestation), and the risk assessment reviewed before postnatal discharge from the hospital, and after every postnatal community visit. 11. National standard for obstetric anaesthetic record-keeping All Trusts must introduce and use standardised approaches to key areas of maternity anaesthetic care to reduce variation and improve outcomes. An agreed minimum standard for obstetric anaesthetic documentation must be implemented. This should include routine recording of intra-operative pain scores and accompanying narrative log, particularly during unexpected or critical events. 12. Safe, accessible and comprehensive maternity anaesthetic documentation All Trusts must strengthen maternal anaesthetic and critical care documentation, ensuring it is clear, contemporaneous and readily accessible, ideally within a single unified electronic patient record. Documentation must capture all relevant multidisciplinary discussions and care plans, and be woman centred, reflecting the woman’s needs, preferences, and involvement in decisions. 13. Department of Health and Social Care/NHS England (DHSC/NHSE) should introduce and support access to coordinated multidisciplinary debrief and psychological support. DHSC/NHSE must support Trusts to ensure that maternity services provide timely, accessible psychological support for women and families following traumatic events. This must include clear referral pathways, adequately resourced specialist provision, and processes that proactively identify and respond to unmet emotional and psychological needs 14. Funding for implementation of maternity Patient Safety Incident Reporting Framework (PSIRF) DHSC/NHSE must provide adequate funding to address the systemic resource gap that prevents Trusts from operationalising new national policy, enabling women and families to experience safer, more consistent care, with improvement demonstrated through full implementation, audit compliance, and sustained delivery of required standards. DHSC/NHSE should develop clear maternity-specific definitions and guidance on patient-safety incidents to resolve national inconsistency in interpretation, ensuring women and families receive transparent and accurate reporting of harm, with improvement evidenced by nationally standardised grading and reliable national data. 15. Strengthened multidisciplinary governance and learning All Trusts must ensure protected time for multidisciplinary governance, review and learning. This must include learning from both adverse events and examples of good practice to support continuous improvement in the quality and safety of care provided to women. Learning from neonatal PSIRF investigations should be considered alongside maternity investigations, recognising the opportunities for shared learning across perinatal services. 16. Foster a compassionate, psychologically safe, and learning culture All Trusts must actively foster a culture of safety, compassion and respect across all maternity services. Staff must feel supported to speak up and raise concerns without fear of reprisal. Women must feel listened to, respected, and fully involved in decisions about their care. Trusts must promote compassionate leadership, a civil and kind workplace, and the use of positive feedback as a tool to reinforce good practice and drive continuous improvement. A psychologically safe and learning culture is essential to improving clinical outcomes, supporting staff wellbeing and enhancing the experiences of women and their families. 17. DHSC/NHSE should recommend and support recruitment processes and implement a consistent onboarding package for new starters Trusts must streamline recruitment processes and implement a consistent onboarding package for all staff involved in the delivery of perinatal care with named supervision and support during initial shifts. 18. All Trusts to ensure compliance, audited annually, with the NHS Records Management Code of Practice post-death care The report also notes that in post-death care, Trusts should cease the practice of conducting post mortem examinations anywhere except the mortuary. They should ensure all investigations or reviews into after-death care include an independent post-death care specialist. Nationally there should be statutory regulation of Anatomical Pathology Technologists introduced.

The long-awaited report into maternity failures at Nottingham University Hospitals NHS trust, the largest investigation of its kind in the UK, involving about 2,500 families, will be published shortly. Led by the senior midwife Donna Ockenden, the inquiry investigated stillbirths, neonatal deaths, maternal deaths and babies or mothers who suffered brain damage and other injuries between 2012 and 2025. In this article some of the families affected share their stories about what happened to them in Nottingham, and explain why this is such a landmark moment.

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