Nottingham maternity scandal

Summary

• Nottingham University Hospitals NHS Trust runs the Queen's Medical Centre and City Hospital. Donna Ockenden's review of its maternity and neonatal care calls itself the largest maternity inquiry in NHS history.
• The problem is that warnings were not acted on. The report describes a persistent failure to listen to and believe mothers and fathers, with problems known about since at least 2010.
• The 520 is not a death toll. It counts cases graded 2 or 3, where different management might have made a difference to the outcome. The report's table gives 444 maternity cases and 76 neonatal cases in those grades, and 444 plus 76 makes 520.
• The dispute is over what should follow. The report points to deeply embedded systemic failures in leadership, culture and staffing. The corporate manslaughter test asks whether the trust caused or contributed to a death through a gross breach of its duty of care.
• In February 2025 the trust pleaded guilty to six charges brought by the Care Quality Commission, the hospital regulator, and was fined £1,667,944. Operation Perth, the police investigation, has reported no charges in the sources checked for this page.

Dig deeper

• The signature case is Harriet Hawkins, who died just before her birth on 16 April 2016. A 2017 external review found the death avoidable. Her parents then faced "almost ten years of obfuscation, delay, callousness and incompetence", in the report's words.
• The report sets out 18 Immediate and Essential Actions for England. The government has since committed to roll out Martha's Rule to all maternity and neonatal wards in England.
• Operation Perth has two strands. In January 2026 the police said they were gathering evidence for the corporate manslaughter probe, and that the wider inquiry also examines whether any individual is responsible. On 22 June 2026 two men were arrested and bailed over mortuary operating practices. No charge has been reported.
• Baroness Amos led a national investigation. Its final report sets out eight recommendations. On 30 June 2026 the government created a maternity and neonatal commissioner and promised a national action plan in December 2026.
• In September 2026 the trust said maternity records from 2011 to 2022 had been overwritten during IT work. Its chief executive, Anthony May, said he was ashamed and embarrassed by the loss.
• Martha's Rule, which lets families ask for an urgent second opinion, began after another family said doctors had not listened to them.

Ethical issues

Interview questions

• What do you know about the Nottingham maternity scandal?
• What happened at Nottingham University Hospitals' maternity services between 2012 and 2025?
• You are a junior midwife on a night shift, and you think a baby's heart trace is being read wrongly. The registrar says it is fine. What do you do?
• Why might a family wait almost ten years for answers, and what would have shortened that wait?
• Should a hospital trust be capable of being guilty of manslaughter? What is the case for and against?
• Why can it be harder to hold an organisation to account than the staff who work in it?
• A family asks you whether their concern was ignored. How do you answer them honestly?
• Would Martha's Rule have changed what happened at Nottingham, and what would it not change?