The maternity of horrors: six women and more than a hundred babies, dead in Nottingham

LondonMore than a decade of negligence, repeated errors, and ignored warnings have been denounced in the devastating report on the maternity and neonatology services of two Nottingham hospitals, which was made public this Wednesday. The analysis of 2,511 cases – occurring mainly between 2012 and 2025, although some date back to 2006 – has allowed the team of independent researcher and midwife Donna Ockenden to document how hundreds of women were subjected to avoidable risks and treated with a "cruelty and brutality" that the report links to a "toxic" care culture. This is one of the most serious scandals in the history of the NHS, which thus adds a new stain to a service in permanent crisis: understaffed and underfunded, and with overwhelmed waiting lists.

The harm caused by a hospital center in a G-7 country and the world's fifth-largest economy is extraordinary and, at the same time, incredible. According to the conclusions presented by Ockenden in a hearing full of dignity and emotion, before some of the families who lost their babies, the review has identified 62 potentially avoidable neonatal deaths, 93 stillbirths that could have been prevented, 105 brain injuries in newborns, and six equally avoidable maternal deaths. "Different care could have changed the outcome," Ockenden said. In addition, 116 cases of potentially avoidable injuries in mothers have been detected, a figure that does not necessarily equate to 116 affected women, as the same patient may have suffered various complications. In total, more than 500 babies and mothers died or were affected.

The mothers' warnings were ignored, and women in intense pain were neglected when they went to the hospitals asking for help. The independent investigation was launched in 2022, after a long campaign by three families who had lost their children in the middle of the last decade. The head of the review has been particularly emphatic in describing the institutional culture detected. The report speaks of an environment where "concerns were silenced, incidents were downplayed, and the voices of women, especially the most vulnerable [black women, young women, or those who did not speak fluent English], were systematically ignored."

Likewise, many mothers were "coerced" into staying at home for too long despite being in labour, amidst a "culture marked by harassment, psychological manipulation, and victim blaming". Women who reported a decrease in fetal movements or problems with the baby's growth were often labelled as "anxious" or told they were "imagining problems".

During the report's presentation, Ockenden described the findings as profoundly alarming. "This is a report that the families of Nottingham should never have needed", she stated. According to the investigator, the same patterns of negligence have been repeated for over a decade, indicating "a failure to listen, a failure to investigate, and a failure to learn". All this was possible for so long because staff "were afraid to speak up", and a small group of managers were allowed to "contaminate" the maternity unit of Nottingham University Hospitals NHS Trust (NUH).

One of the central concepts of the report is the "normalisation of deviance", an expression used by investigators to describe a situation where clearly inappropriate practices become commonplace. According to Ockenden, there was an obsession with achieving vaginal births considered "normal", even when there were medical indications recommending faster interventions, such as emergency caesarean sections.

Insufficient templates, limited resources

However, and perhaps this is another of the most worrying aspects because it suggests systemic failure, Ockenden has avoided exclusively blaming healthcare staff. And he has highlighted that many professionals were working under enormous pressure, with insufficient staffing and limited resources. "This is a report about a system that failed. And when systems fail, the cost is measured in lives, in truncated futures, and in devastated families."

At this point, he introduced the concept of "avoidable harm," which implies "a particular cruelty." "It is not just the loss of a life, which is devastating enough, but also the loss of all that would have come after," he said. And Ockenden evoked "the first day of school that will never arrive, the teenage arguments that will not happen, the graduations, the weddings, and even the grandchildren who will never exist."

The review also points to the responsibility of medical and nursing regulatory bodies. According to the families, for years they were faced with "a closed door and a brick wall" when trying to report possible negligence. Among the most striking aspects of the report are those relating to post-mortem care. The review documents 18 serious cases of deficiencies, some of which led to a grave loss of dignity for the deceased and immense suffering for the families.

In one case that occurred in 2016, a deceased baby was placed in a mortuary storage space already occupied by an unknown adult. The family was not informed of the incident until this year. In another case, in 2019, the remains of a very premature baby were accidentally disposed of as clinical waste, despite the parents' express wishes to give it a suitable burial.

The conclusions come at a time of growing concern about maternal health across England. Ockenden recalled that the commitment made in 2015 to halve maternal and stillbirth deaths by 2030 is far from being met. Maternal deaths are currently at their highest level in twenty years, while black women and those living in more disadvantaged areas continue to have mortality rates much higher than the national average.

For Ockenden, the Nottingham tragedies cannot be considered an isolated incident. They are, he has warned, the most extreme expression of structural problems present in other parts of the British healthcare system. "Safe and equitable obstetric care is not a luxury. It is a fundamental obligation of a civilized healthcare service," he concluded.