We should have never had to fight in the first place
On Wednesday, the NHS will release the findings of its largest-ever maternity review, examining thirteen years of preventable deaths and avoidable harm at Nottingham University Hospitals — a reckoning shaped by the grief of 2,500 families who refused to let institutional silence stand as the final word. Led by senior midwife Donna Ockenden, the review arrives alongside criminal investigations, record fines, and the quiet, persistent question that haunts every such inquiry: how does a system entrusted with new life allow so much of it to be lost? The answer, when it comes, will carry consequences not only for one trust but for the culture of maternity care across the entire health service.
- Thirteen years of maternity failings at two Nottingham hospitals have left hundreds of families carrying losses that should never have been theirs to bear.
- A criminal manslaughter investigation is already underway, with two men arrested on suspicion of misconduct in public office linked to how the trust handled its mortuary service.
- The trust has paid out millions in compensation — including a record £1.6m fine and a £2.8m settlement in a single stillbirth case — yet families insist money cannot substitute for accountability.
- Regulatory bodies are now scrutinising 96 nursing and 62 medical staff cases, with one midwife already barred from practice while investigations continue.
- The report's publication is expected to trigger systemic reform across the NHS, as families demand that the estimated 1,000 avoidable baby deaths occurring in Britain each year finally be treated as a national emergency.
On Wednesday, the NHS will publish the largest maternity review in its history — a document drawn from the experiences of 2,500 families and more than 800 staff, examining failings at Nottingham University Hospitals across thirteen years at two maternity units. Led by senior midwife Donna Ockenden, the review covers the period from April 2012 to May 2025 and arrives at a moment when the trust is already facing criminal scrutiny, record financial penalties, and the grief of families who spent years fighting to be believed.
The trust has paid millions in compensation, including a record £1.6 million fine for maternity failures linked to three baby deaths in 2021. Nottinghamshire Police launched a manslaughter investigation in June 2025 — Operation Perth — which has already led to the arrest of two men on suspicion of misconduct in public office connected to the trust's mortuary service. Both were released on bail.
Among the families at the centre of the review are Sarah and Jack Hawkins, whose daughter Harriet was stillborn in April 2016. When the hospital's own review found no obvious fault, the couple — both trust employees — demanded an external investigation. It found numerous failings and concluded Harriet's death was almost certainly preventable. They later discovered the trust had allowed their daughter's body to decompose so severely it had to be triple-bagged for her funeral. Their legal settlement of £2.8 million is believed to be the largest ever made in a stillbirth negligence case in Britain.
Gary and Sarah Andrews lost their daughter Wynter just 23 minutes after her birth in 2019. The trust admitted failures in both Wynter's and her mother's care, and was fined £800,000. The couple now have a four-year-old son, Bowie, and Sarah has spoken of how each milestone he reaches sharpens the absence of his sister. "We should have never had to fight in the first place," she said.
Regulatory bodies are now examining individual staff: the Nursing and Midwifery Council is investigating 96 cases, with one midwife already subject to an interim order preventing practice; the General Medical Council is reviewing 62 cases and more than 300 information reports passed from the review itself. For the families involved, Wednesday's publication is not an ending — it is a test of whether institutional reckoning can translate into genuine, lasting change.
On Wednesday, the NHS will publish the largest maternity review in its history—a document born from the experiences of 2,500 families and more than 800 staff members, all of whom have spent years trying to understand how a major hospital trust allowed babies to die and mothers to suffer preventable harm. The review, led by senior midwife Donna Ockenden, examines failings at Nottingham University Hospitals across thirteen years, from April 2012 through May 2025, at two maternity units: Nottingham City Hospital and the Queen's Medical Centre.
The trust has already begun paying for what happened. It has handed over millions in compensation and fines, including a record £1.6 million penalty—the largest ever imposed on an NHS trust for maternity failures—related to the deaths of three babies in 2021 alone. Yet the financial reckoning is only part of the story. Nottinghamshire Police launched a manslaughter investigation into the trust in June 2025, an operation they call Perth, which has already resulted in arrests. On Monday, police confirmed they had detained two men, aged 55 and 59, on suspicion of misconduct in public office connected to how the trust's mortuary service operated. Both were released on bail with strict conditions. The criminal investigation continues alongside the review's publication.
Sarah and Jack Hawkins were among the first to push back against the trust's account of what went wrong. Their daughter Harriet was stillborn at City Hospital in April 2016. The hospital's initial review concluded there was no obvious fault—that Harriet had died of an infection. But Sarah and Jack, both employees of the trust themselves, refused to accept that explanation. They demanded an external review. When it came, in January 2019, it found numerous failings and concluded that Harriet's death was almost certainly preventable. The couple later discovered that the trust had allowed their daughter's body to decompose so severely it had to be triple-bagged for her funeral. Their legal settlement reached £2.8 million, believed to be the largest payout ever made in a stillbirth clinical negligence case in Britain. Jack, now 57, a hospital consultant at the time of Harriet's death, has spoken about the scale of the problem: roughly 1,000 avoidable baby deaths occur in Britain each year, he noted, yet at this one trust, the number of children lost or permanently harmed has been so large it amounts to entire schools' worth of children.
Gary and Sarah Andrews lost their daughter Wynter just 23 minutes after she was born in 2019. The trust admitted failures in both Wynter's care and her mother's care, and was fined £800,000 in January 2023. The couple now have a son, Bowie, who is four years old. As he grows and reaches milestones, Sarah said, the absence of Wynter becomes sharper. "We should have never had to fight in the first place," she said, "and actually we should not be doing it now." The families want accountability. They want their children's names cleared. They want the harm caused to be recognized as the trust's responsibility, not theirs.
Regulatory bodies are now examining individual staff members. The Nursing and Midwifery Council is investigating 96 cases related to maternity care at NUH. Of those, 80 are still in initial assessment, 15 are undergoing full investigations, and one midwife has already been investigated and is subject to an interim order preventing them from practising. The General Medical Council, which oversees doctors, is looking at 62 cases—53 at initial stage, nine in early investigation—and is also reviewing more than 300 information reports passed to them from the Ockenden review itself.
The publication of this review is expected to reverberate across the entire NHS. It has already prompted a national inquiry into maternity failings. For the families involved, the report represents a moment of reckoning—a chance for their experiences to be documented, their losses acknowledged, and their calls for systemic change to be heard not just locally but across the health service. What happens next will determine whether this review becomes a turning point or simply another document in a long history of institutional failure.
Citas Notables
How on earth have we allowed it that there are 1,000 avoidable baby deaths in this country every year?— Jack Hawkins, whose daughter Harriet was stillborn in 2016
There should be accountability, and it shouldn't be on families to have to fight to be heard and believed.— Sarah Andrews, whose daughter Wynter died in 2019
La Conversación del Hearth Otra perspectiva de la historia
Why did it take so long for the external review to happen? The hospital's own investigation said there was no fault.
Because the parents didn't accept that answer. They worked at the trust themselves—they knew something was wrong. It took them pushing hard, refusing to let it go, before anyone looked again. And when they did, the second review found the death was almost certainly preventable.
What does it mean that the trust has already paid out millions? Doesn't that suggest accountability has already happened?
The money is compensation for the families. It's not the same as systemic change. You can pay settlements and still have the same problems happening in the same units. That's partly why the police investigation is running alongside the review—because money alone doesn't answer whether people should face criminal charges.
The review covers thirteen years. How many families are we talking about?
Twenty-five hundred families contributed to this review. That's 2,500 separate stories of loss or harm. The review looked at two maternity units, and the failings were widespread enough that it became the largest maternity review in NHS history.
What do the families actually want now?
They want their children's names cleared—they want it on record that what happened wasn't their fault. They want accountability from the institution. And they want the NHS to change so it doesn't happen again. One father pointed out that roughly 1,000 babies die preventably in Britain every year. At this one trust, the number was concentrated enough that it amounts to entire schools' worth of children.
Are individual staff members being held responsible?
Yes, but it's a slow process. The nursing regulator is investigating 96 people, most still in early stages. The medical regulator is looking at 62 cases. And police have made arrests related to how the mortuary service operated. But these investigations take time, and for families waiting for answers, that delay is its own kind of harm.
What happens when the review is published?
It becomes public record. It becomes evidence. It's expected to prompt changes across the entire NHS, not just at Nottingham. But whether those changes actually happen, and whether they're enough—that's what families and regulators will be watching for.