The review was commissioned following sustained concerns raised by families and regulators about the safety and quality of maternity services, including cases of serious harm and deaths, and calls for a fully independent investigation.
One of the largest of its kind in NHS history, it examined the care of hundreds of families over a number of years and sets out a series of findings and recommendations aimed at improving the safety and quality of services.
The Nottingham review follows an earlier review into the Shrewsbury and Telford Hospital NHS Trust published in March 2022. This outlined 22 immediate and essential actions for maternity systems across England. The immediate and essential actions published in June 2026 build on the Ockenden’s previous findings and actions and are grouped under eight key headings:
- Listening to Women and Families
- Workforce Planning and Safe Staffing
- Training and Multi-Professional Learning
- Risk Assessment Throughout Pregnancy
- Incident Investigation and Family Involvement
- Governance and Board Accountability
- Culture, Teamwork and Psychological Safety
- Mothers Who Have Died and Post Death Care
Further detail can be found in the final report.
In response to the publication Steve Turner, President at the Royal College of Paediatrics and Child Health said:
The findings of this review are deeply distressing, and first and foremost our thoughts are with the women, babies and families who have been affected. We also want to acknowledge the extraordinary courage of the families who engaged with this review and shared often painful experiences in the hope of preventing others from suffering similar harm.
We welcome Donna Ockenden’s recommendations and the renewed focus on strengthening safety, accountability and learning across services. Alongside action to address inequity and variation in care, these measures are an important step towards ensuring that every baby and family receives consistently safe, compassionate and high-quality care.
The publication of this review must be a turning point. We owe it to the families who contributed to ensure that its findings lead to meaningful action, lasting improvements in care, and better outcomes for women, babies and families.
The British Association of Perinatal Medicine said in a statement:
We are deeply grateful to the families involved in this comprehensive report for their courage in sharing their experiences for the benefit of others. At BAPM, we will take time to reflect carefully on the findings, and consider how we can best support the recommendations so that they lead to meaningful and lasting improvement.
We acknowledge the review’s recognition of examples of good and excellent neonatal care delivered by committed multi-disciplinary teams, while also recognising the serious failings identified, their devastating impact on babies and families, and the urgent need for action to prevent future harm.
While the report focuses on services in Nottingham, most of the themes identified have relevance in maternity and neonatal services across the United Kingdom. We therefore recognise the importance of learning from these findings nationally to improve the safety, quality experiences of care for women, babies and families.