Review Identifies 'Systemic' Failings in Nottingham Maternity Services

An independent review has identified "systemic" failings within the maternity services operated by Nottingham University Hospitals NHS Trust. Donna Ockenden, who chaired the review, presented the findings, which covered a period from 2006 to 2023.

The report detailed extensive issues across various aspects of care. Investigators found breakdowns in communication among staff, inadequate staffing levels, and insufficient training. These factors contributed to repeated errors and missed opportunities for intervention in patient care.

The review also addressed the organizational culture within the trust. It described an environment where staff often felt unable to raise concerns, and where an emphasis on targets sometimes overshadowed patient safety. The report indicated that these cultural elements contributed to the sustained nature of the problems identified.

Investigators examined numerous cases involving adverse outcomes for mothers and babies, including stillbirths, neonatal deaths, and maternal injuries. The report concluded that improved practices could have altered outcomes in a number of these instances. The review called for significant changes to address the root causes of the identified problems.