The Ockenden Report: A call for adequate resourcing, organisational learning, and compassionate, evidence-based care.
What is the Ockenden report?
The Ockenden report was a national inquiry into the Nottingham University Hospitals NHS Trust (NUH) by senior midwife, Donna Ockenden. Published in June 2026, it found that over 444 women and 76 newborn babies suffered potentially avoidable outcomes as a result of poor treatment. The report followed three similar reports from other NHS Trusts in England (Morecambe Bay, East Kent and Shrewsbury and Telford). Whilst the report found multiple individual instances of good practice, it also found widespread systemic issues in NUH maternity care. Its focus has therefore been on understanding how such issues arise and how they might be improved.
Healthcare for Both Lives seeks to promote the care of both mothers and their children. As an organisation, we therefore welcome the Ockenden report for its investigation and suggested improvements in maternal care.
What does the Ockenden report show about the principles of caring for mothers and babies?
Drawing on the findings of the report, this blog will focus on four themes that emerge as particularly important: evidence-based care, adequate resourcing, organisational learning, and compassionate care.
Harriet Hawkins story
Sarah and Jack Hawkins' daughter, Harriet, was stillborn at Nottingham City hospital in April 2016. Harriet’s story was selected as the exemplar case to demonstrate, in the words of the review, ‘the human impact of failings in a way that is accessible, meaningful and grounded in lived experience.’
Harriet died intrapartum after a prolonged labour, complicated by malposition, and with multiple missed opportunities to escalate based on parental concerns. Harriet’s parents, Sarah and Jack were both employed by NUH as a physiotherapist and a consultant respectively. The review identified 9 missed opportunities where a different action could have altered the outcome. These missed opportunities centred around staff repeatedly dismissing the couple’s concerns or assuming Sarah’s labour was “normal” rather than recognising its prolonged course and heeding the concerns raised by Sarah and Jack. Consequently, opportunities for further investigations and escalation of care were missed.
Unfortunately, after Harriet’s death, her parents also describe multiple interactions with staff as lacking compassion and with some responses experienced as defensive. Harriet’s story, together with the wider findings of the Ockenden report, highlighted failings at several levels in the maternity care and helped show what these failings mean for the individuals and families involved.
Evidence-based care
The report highlighted the importance of evidence-based medicine. It highlighted that we must train and equip midwives, obstetricians, anaesthetists, critical care teams and neonatal teams with the skills needed to deliver high-quality, enhanced maternal care.
In particular, the review highlighted several areas where greater research and thereby more consistent evidence-based practice is needed. This included: 1) standardising and recording fetal growth assessment to ensure consistency in the approach to reducing the risks of still birth; and 2) developing a greater understanding and structured assessment for the latent phase of labour, with clear guidance about when escalation is required.
The report also highlights the importance of conveying accurately information around terminations. One case study on ‘Baby Ladybird’ describes how: “Carly Wesson and Carl Everson were incorrectly advised to terminate their pregnancy at NUH in 2019. Subsequent investigations revealed their daughter ‘Ladybird’ was a healthy baby. The lifelong psychological trauma for this family is immeasurable. For Carly and Carl, the weight of their loss is inseparable from the fact that the decisions made were based on misinformation. The subsequent SI [serious incident] process was flawed, with inaccurate findings. The Trust was required to repeat the investigation due to the significant errors found within the initial report.” The couple were told that a chorionic villus sampling (CVS) result indicated that their daughter had Patau’s syndrome, which often results in stillbirth or death shortly after birth. Outside the report, the couple stated that during their conversation with a fetal medicine consultant, they were told that a more detailed analysis would not show a different outcome. However, the second test indicated that their daughter did not have the condition. Their story highlights the need for careful review and interpretation of predictive or diagnostic results, and ensuring that parents are given full information when facing such decisions. Perhaps we might also be reminded of the need to ensure that legal safeguards, such as the requirement for a second sign-off in termination requests, operate as meaningful opportunities for independent scrutiny, rather than merely administrative hurdles.
Properly resourced care
One thing that was particularly striking, and highlighted repeatedly in the Ockenden report was that the medical maternity units and postnatal wards in NUH were chronically understaffed. Approximately 800 staff members contacted the Ockenden report, but only 11% reported sufficient staffing. As healthcare professionals, we need to remember that proper staffing is not simply a luxury, but is in fact a necessity for good patient care, and we need to advocate for this in the best way possible.
This lack of resourcing also had consequences for how care was organised and delivered. For example, it was noted that some women were viewed as “bed-blocking” particularly if they presented in the latent phase of labour. There appeared to be a poor use of telephone triage and follow-up, highlighting the importance of recognising when face-to-face assessment is needed. This has wider relevance across medicine, highlighting how systems designed to manage and distribute workload helpfully, might themselves be detrimental when facing certain system pressures. Telephone triage, for example, can facilitate safe and efficient care, but becomes risky if it is used primarily as a barrier to assessment rather than as a means of facilitating appropriate, patient-centred evaluation. This highlights that properly resourced care can be supported, but not replaced, by appropriate tools.
The report also emphasised that babies on the postnatal ward should be viewed as separate, distinct patients, and that this needs to be reflected when considering staffing numbers. In other words, safe staffing must account for the needs of both mother and baby. Healthcare for Both Lives strongly supports this recognition.
Organisational learning
Beyond staffing issues being dismissed or downplayed, the Ockenden report also found that NUH frequently missed opportunities to learn from prior mistakes. The report highlighted a number of times where internal investigatory processes by NUH into serious incidents were not of the expected standard. The Trust was found to have downgraded serious incidents and appeared to try to limit external scrutiny. In doing so, the Trust lost repeated opportunities to learn from prior experience and implement necessary changes. Good medicine requires a willingness to openly acknowledge and learn from mistakes. Trust is needed for any good clinician-patient relationship, which itself requires open, honest communication.
This is reflected in the GMC duty of candour: “Every health and care professional must be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress.” The Ockenden report serves as a timely reminder that improving maternity and neonatal care will require acknowledging areas in which improvements are needed.
Organisational learning reminds us that we must seek to learn both from the decisions made by individual professionals, and also from the culture and working environments within which these decisions are made. Creating a learning environment, where staff feel safe and supported to raise patient safety issues is a key aspect of a safe and effective learning culture.
Compassionate care
Another repeated theme of the report was the need for compassionate care. This involves truly listening to parents, and treating mother and baby, both in life and in death, with respect and dignity.
For example, the Ockenden report recognises that had the “basic need” for compassionate care been met, with Sarah Hawkins pain and escalating concern heeded, “it is highly likely that Harriet would not have died during labour.” The report found multiple other instances of women in labour being dismissed at triage, being denied timely assessment and/or being denied timely pain relief. This was particularly found to be the case for women from ethnic minority backgrounds, or for whom English was not the first language. One recommended nationwide action from the review team is therefore that all families and staff should be able to seek an additional clinical review, using Martha’s rule.
The review also emphasises explicitly that compassionate care involves careful use of language. In considering failures in care after death, the review described the dehumanising terminology sometimes used by clinicians when referring to babies. Parents recalled terms such as “fetus”, “sample” and “specimen” being used. Families felt, in the words of the report, that such language “reduced their baby to a lesser status.” As one parent put it, “[h]e becomes a test that needs actioning rather than a little boy.” More broadly, beyond the scope of the Ockenden report itself, one might wonder whether the more distancing language often used in the context of termination has influenced the language used for babies before birth more generally. Perhaps this might make it harder to return to more humanising language in cases of stillbirth or neonatal death, where parents may understand and speak of the baby very differently.
It is noteworthy that the report itself was careful in its use of language. When discussing the treatment and assessment of Harriet Hawkins, daughter to Jack and Sarah Hawkins, whose death became the index case for the review, she was consistently referred to as ‘Harriet’ rather than, for example, ‘the baby’. In doing so, the report itself offers a powerful example of how careful language can help us recognise and acknowledge the distinct individuals at the centre of obstetric care.
This compassionate and dignified treatment must continue after death. The review describes one family’s experience where their very early gestational baby who was inadvertently treated as clinical waste by the laboratory staff after her post mortem examination, despite the express wishes of her parents who said, “We didn't want the baby to be disposed of. That was the main thing we didn't want.” This failure painfully illustrates how the dignity of early gestation babies can sometimes be overlooked, and can compound their parent’s grief.
The report also highlighted the life-changing and catastrophic impact of the death of a woman during or after pregnancy. Families poignantly reflected on the loss of their loved ones. The bereavement care provided to families of the women who died at NUH was sadly variable. Whilst multiple good examples of bereavement care were detailed, many families demonstrated feeling ‘left’ to navigate this period with minimal support. Again, the importance of truly compassionate care is evident.
Summary
Taken together, the report demonstrates that good maternity care must be properly resourced, evidence-based, compassionate, and actioned within a workplace that encourages organisational learning. Each of these principles reinforces the others. By giving voice to women and families impacted by substandard care the review emphasises the human impact and consequences of maternity care.
It is important that, while we acknowledge and must learn from serious failures in care, we also recognise that many healthcare professionals continue to strive to provide excellent and compassionate care within a pressured healthcare system. The Ockenden report itself noted many examples of excellent individual practice, despite chronic understaffing and a challenging work culture.
This blog aims not just to critique, but rather to highlight areas where the report shows we should advocate for improvement: be that in research, in staffing, in culture, or in our own use of language. This does not lessen the need for serious self-examination within our healthcare professions, nor the very real harm that professional and systemic failings can cause to patients. Rather, understanding these harms and impacts should rally us to improve the care we provide and the systems in which that care is offered.
More broadly, Healthcare for Both Lives and its declaration, seeks to affirm and support healthcare workers in their professional responsibility to care for both pregnant women and their preborn children.
[2] https://www.matneoinv.org.uk/wp-content/uploads/2026/06/East-Kent-Hospitals-University-Foundation-Trust-Report.pdf
[4] P39 FINDINGS, CONCLUSIONS AND ESSENTIAL ACTIONS from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust, 24 June 2026
[5] p4, FINDINGS, CONCLUSIONS AND ESSENTIAL ACTIONS from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust, 24 June 2026
[7] PXI, FINDINGS, CONCLUSIONS AND ESSENTIAL ACTIONS from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust, 24 June 2026
[8] P48, FINDINGS, CONCLUSIONS AND ESSENTIAL ACTIONS from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust, 24 June 2026
[9]https://www.gmc-uk.org/professional-standards/the-professional-standards/candour---openness-and-honesty-when-things-go-wrong/the-professional-duty-of-candour
[11] https://www.gmc-uk.org/professional-standards/the-professional-standards/candour---openness-and-honesty-when-things-go-wrong/the-professional-duty-of-candour
[12] P50, FINDINGS, CONCLUSIONS AND ESSENTIAL ACTIONS from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust, 24 June 2026
[13] For more on Martha’s rule see: https://www.bmj.com/content/392/bmj.s458
[14] P329, FINDINGS, CONCLUSIONS AND ESSENTIAL ACTIONS from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust, 24 June 2026
[15] P236 Ibid.
[16] P233 Ibid.
