The report of the Nottingham maternity inquiry, published on Wednesday, makes for harrowing reading.
The review includes 520 cases involving babies and mothers who died or suffered catastrophic harm as a result of care failings at maternity units under the Nottingham University Hospitals (NUH) NHS Trust.
Failings were “hauntingly consistent” for more than a decade, said Donna Ockenden, the senior midwife who led the inquiry, with “concerns suppressed, incidents downgraded, and the voices of women, particularly the most vulnerable, systematically dismissed”. Women and staff were bullied and gaslit, with some told they were imagining their pain.
The damning assessment continues throughout 400 pages of heartbreaking detail. But at the core of the report is the message that the NHS has once again failed to take proper care of women.
The Nottingham inquiry is the fifth major review of maternity failings in the UK since the 2015 report into Morecambe Bay Hospitals. Next week, another government-commissioned rapid national review of maternity services at 14 NHS trusts is due to be published, amid concerns about the overall treatment of women and babies in these settings.
And another two inquiries, also led by Ockenden, will take place into suspected maternal failings at Leeds Teaching Hospitals NHS Trust and University Hospitals Sussex NHS Trust. The Nottingham scandal is, quite clearly, not an isolated case – and the report is a scathing indictment of the poor maternity care given to thousands of women across the country.
Ockenden pulled no punches when delivering the report. In her speech on Wednesday, she said the recommendations made in her 2022 inquiry into maternity care at Shrewsbury remain largely unimplemented. In essence, lessons have not been learnt.
In January this year, an expert report warned that the overall rate of maternal death in the UK was at a 20-year high, and 20 per cent higher in 2022-2024 than in 2009-2011, when the government promised to halve the number. It has long been known that women from Black and minority ethnic backgrounds, and those living in the most deprived conditions, have the highest death rates.
The common thread running through all of these reports is the institutional failure by the NHS to listen to women or prioritise their safety and, as a result, the safety of their babies.
As the report said, “Listening to women is not simply an important principle of maternity care; it is its foundation.”
It went on: “When women’s voices are heard, valued, and acted upon, services are better able to provide personalised, respectful, safe, high-quality care across the entire maternity journey.”
Reviewers found that a recurrent pattern was women describing that their instincts or concerns were minimised or reframed as anxiety, and that women reported feeling told off, blamed or judged when raising concerns.
The case of Jack and Sarah Hawkins, for example, who were spotlighted in the Nottingham report, revealed how baby Harriet Hawkins died just before her birth on 16 April 2016. Sarah’s symptoms and concerns were not acted upon, with Sarah being repeatedly told she was “not in labour”.
The Hawkinses were initially misled as to the cause of Harriet’s death, and then were forced to spend years fighting for answers.
After three internal investigations, a fourth, external review published in December 2017 confirmed that Harriet’s death was avoidable and was due to the poor care her mother received in the very latter stages of her pregnancy.
Tragically, these stories are not confined to Nottingham or Shrewsbury but are seen across the country. Former health secretary Wes Streeting previously told The Independent that medical misogyny is rife in the NHS – and is an issue that is bigger than maternity services.
Concluding her speech on Wednesday, Ockenden said that “safe maternity care is not complicated in its ambition”.
“Women and their families come to maternity services with modest expectations – competence, honesty, timeliness, safety, dignity and kindness,” she said. “These are not high bars.”
Indeed, treating patients with dignity and competence should be the foundation of the NHS. But without addressing the simple issue that women’s voices are being ignored, can the NHS’s maternity care problem ever truly be resolved?
