Senior midwife Donna Ockenden has published the findings of the largest maternity review in NHS history, investigating stillbirths, neonatal and maternal deaths, and cases of brain damage and other injuries at Nottingham University Hospitals Trust.
The report, described as 'truly horrific' by observers, catalogues stories of women and babies who suffered harm. Parliamentary and health service ombudsman Paula Sussex stated that the review adds to an 'overwhelming body of evidence that maternity services are failing women and families in ways that are repeated and preventable.'
Sussex noted that for years, reviews have highlighted the same issues: failures in communication, not listening, delays in diagnosis, and poor postnatal care. She warned that warnings and lessons have 'not translated into lasting improvement, resulting in repeated harm.'
The ombudsman emphasized that 'every woman and baby deserves safe, compassionate care, every time' and called on NHS leaders to ensure the findings lead to 'real, sustained action across all Trusts.' The focus must now be on fixing the service, she added.
Critics may argue that without new legally binding mandates or independent oversight, the report's recommendations risk being absorbed into the same cycle of inaction that has characterized previous reviews.