Today, 24 June, Donna Ockenden has published the final report of the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust. The report looks at the provision of maternity and neonatal care at Nottingham University Hospitals Trust (NUH) between 2012 and 2025, following an in-depth review of 2,500 cases.
Caroline Lee-Davey, Chief Executive of the UK’s leading neonatal charity Bliss, commented: “This report is devastating to read, and sets out a clear pattern of systemic failures through which many women and babies suffered avoidable harm. The failings exposed in this report represent many hundreds of families whose lives have been changed forever, and their pain is unimaginable. We extend our deepest sympathies to all the families affected, and recognise their courage in ensuring that today’s findings have been brought to light.
“The themes in this report chime with those identified in previous reviews and investigations, and include a toxic workplace culture, failure to escalate concerns, chronic under-resourcing, and not listening to women and families. There is also a clear theme of poorer care, experiences and outcomes for women and babies from minority ethnic or disadvantaged backgrounds, with existing inequalities compounded by unequal treatment.
“Critically, the delays in addressing known concerns mean that many more women and babies were harmed even after initial issues had been identified. It is a shocking failure that in neonatal care it took nearly 20 years before the known challenges of having a split-site neonatal intensive care unit (NICU) – where NICU care was provided between both Queen’s Medical Centre and Nottingham City Hospitals – with both cot capacity and staffing pressures, were finally addressed with the opening of a new single-site NICU in late 2024. This led to multiple inappropriate transfers of very vulnerable babies between sites, and cross-site consultant on-call arrangements which led to delays in senior review of cases out of hours.
“The report is clear that neonatal care was broadly delivered in line with national standards with many examples of good practice, and compassionate, family‑centred care evident throughout. However, in addition to the significant impact of split-site working and staffing pressures over many years, there were a number of cases of poor neonatal care identified across specific areas of practice, with significant delays in addressing these.
“We welcome the focus in the recommendations on delivering a consistent Family Integrated Care approach in neonatal services which ensures parents are partners in their baby’s care, as well as the recognition of the additional work needed to improve communication and relationships with women and families from minority ethnic or disadvantaged backgrounds. We also support the clear recommendations for specific changes to neonatal clinical care and pathways, to ensure consistent and high-quality care for all vulnerable babies in line with best practice.
“For neonatal services and governments across the UK, this report must also be a wake-up call about the urgency of addressing identified issues which are causing harm. For the smallest and sickest babies, being born into services which are configured to provide all the care they need has a tangible impact on their chance of survival, as well as on their long-term health. When the need for major service change is identified – including to unit reconfiguration and cot capacity – it is simply unacceptable that it should take so many years to put in place. We must learn from this review and ensure that the needs of babies born premature or sick, and their families, are prioritised now and into the future”.
What does the report say specifically about neonatal care?
The report highlights the following specific areas of concern relating to neonatal care provided during this period:
- Guidance for and some instances of newborn resuscitation that were not in line with national guidance and best practice
- A recurrent pattern of cases where national guidance was not followed in relation to active cooling for babies at risk of brain injury following oxygen deprivation
- Higher rates than comparable units of babies undergoing multiple intubations, as well as of unplanned extubations (where a breathing tube is unintentionally taken out or removed too early), with delays in adoption of national best practice on airway management
- A number of cases in which there were serious concerns about the prevention, recognition and management of hypoglycaemia (where blood sugar drops too low) in newborn babies
- Multiple concerns raised by families about infection prevention practices among staff, as well as physical conditions on the unit leading to infection outbreaks
- A pattern of clinical practice relating to antibiotic use not consistently following national guidelines
- A cultural acceptance that pressure sore and skin wounds – relating to how respiratory support was placed on preterm babies – were inevitable, with opportunities for prevention and timely escalation missed
- A recurring discrepancy between the standard of documented communication and the experience reported by families in interviews, whereby some parents felt they were not kept informed, that their concerns were not acted upon, and that they were not told about planned procedures
- Cases were also identified in which parental concerns were not adequately heard or acted upon, with serious consequences
- Some instances where parents experienced extended separation from their babies – even outside of the Covid period – and opportunities for parents to hold their babies in the delivery room not always offered or facilitated
- A consistent theme of families feeling excluded from patient safety investigations into the care of their babies.
Across the review more widely, inequalities in the care and treatment of women and babies from minority ethnic or disadvantaged backgrounds is identified, with clear themes emerging relating to communication failures, not being believed, cultural misunderstanding, fear, mistrust, and power imbalance, and systemic barriers. These chime with the findings in Bliss’ forthcoming report on neonatal inequalities, Equity for Every Baby, being launched on 2 July.
The report sets out a series of Immediate and Essential Actions to Improve Care, including a series of neonatal-specific actions. At national level, these include: a focus on consistent delivery of a Family Integrated Care approach, where parents are recognised as partners in care and communication with parents is prioritised; neonatal staffing to be in line with national standards across the multi-disciplinary team; and a series of improvements to resuscitation, airway management, and infection control measures.
