Donna Ockenden told the BBC she hopes the process of "family feedback" will provide families with "the answers they have waited for so long".

Families are expected to receive their feedback by the end of 2026 at the latest.

Each family in the maternity review is assigned a case number. The lower the number, the sooner they will receive their feedback, as the numbers reflect the order in which cases were added to the review.

"I suspect the vast majority of families will receive their report and won't have further questions. However, there are various options depending on the family's needs and how serious, or not, our findings are," Ockenden said.

"I have said that where mothers have died, even where the care is appropriate, we will offer an opportunity for face-to-face meetings in Nottingham. In addition, for all families where we find major concerns, they will be offered the opportunity, if they want it, for face-to-face meetings.

"We will also offer virtual meetings and telephone conversations - no-one is on their own on receipt of their family feedback."

Ockenden said women’s consent was not sought during labour and some interaction from staff was at times "cruel".

Women in the middle of labour were told to "pull themselves together" while another submission from a mother recalled how she was told to “wait their turn” as there was “other women they had to sort.”

Ockenden said her team found examples of what she described as the "normalisation of deviance" and there were significant concerns raised as there should have been medical interventions but natural birth continued.

She added: "These were not isolated incidents… this was a pattern that caused long-term harm.

"Some of those babies are no longer here or suffered serious harm."

Ockenden's report also outlines a set of local actions for learning (LAFLs) for NUH.

The LAFLs directly address the failures identified by the review team and are specific actions for the trust to take.

These include:

• Urgent improvements to risk management and monitoring
• Strengthening escalation protocols, communication and safe transport of care
• Improving neonatal safety and care
• Standardising emergency care and reducing variation in practice
• Governance, leadership and accountability
• Treatment of families during investigations in care
• Improving psychological support for families and staff
• Improving communication, administration and implementation of change
• Improving post-death care and bereavement processes

Warning: This post contains details that some may find distressing

We heard Donna Ockenden discuss post-death care at NUH, including a "very serious incident" in 2022 involving the release of the wrong baby to a funeral director.

In the report, one instance in 2019 was also highlighted, when "one very early gestation baby was inadvertently disposed as clinical waste by laboratory staff after her post-mortem examination, resulting in a complete loss of dignity for the baby and significant distress to her parents".

Separate to today's report findings, Nottinghamshire Police announced on Monday that two men had been arrested by officers investigating maternity failings in connection with operating practices at the city's mortuaries. They have since been bailed.

Ockenden and her review team have set out a list of what are called "immediate and essential actions (IEAs)" to improve maternity care and safety across England, not just in Nottingham.

They have been developed from the findings of the review and are "urgent, system-wide actions that must be implemented to address the most pressing risks".

The key headings for the IEAs - as listed in the report - are as follows:

• Listening to women and families
• Workforce planning and safe staffing
• Training and multi-professional learning
• Risk assessments throughout pregnancy
• Incident investigation and family involvement
• Governance and board accountability
• Culture, teamwork and psychological safety
• Mothers and babies who have died and their post-death care

Following publication of Donna Ockenden's report, Nottingham University Hospitals (NUH) NHS Trust chairman Nick Carver and chief executive Anthony May have issued an open letter, addressed to "the people and communities of Nottinghamshire".

Here it is, in full:

"The publication of the independent review into maternity services in Nottingham is a watershed moment for affected families, our staff and for the communities we serve. We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services.

"We failed you, and on behalf of Nottingham University Hospitals Trust, we accept responsibility for our failings.

"Many families have been generous enough to meet with us, showing extraordinary courage and determination. We are grateful for that, and we want you to know that the publication of this report is not the end of a process. It is another important milestone in a journey that must continue. Your bravery and commitment to speaking up is helping improve maternity care.

"We want to thank Donna Ockenden for her work and for engaging with us throughout this process. Donna’s review has provided an opportunity to hear directly from thousands of families and staff. The direct feedback we have had throughout has helped us with our improvement efforts. As a result, whilst there is more to do, important changes have been made and we believe our services are now safer, kinder and better led.

"We recognise that trust is earned through actions, not words. We know, also, that families and the wider public will judge us not by what we say today, but by what we do next.

"The review makes clear that while improvements have been made, there is still more to do. We will take time to reflect on the report with humility, honesty and determination. At the same time, we will work with families on a meaningful apology because we know it is important to them that this is reflective of the findings of the review, and our commitment to lasting improvement. We can say with certainty that families will continue to be involved in our improvement plans because this review has proved that we can learn from them.

"We must also acknowledge our staff. Every day we see dedicated, compassionate professionals working tirelessly to provide the best possible care for women and families, often under extreme pressure and scrutiny. Whilst the publication of the report will be difficult for them too, we know they will reflect on the findings of the review and see this as an opportunity to continue our improvement journey. To these colleagues, we want to say that we know that we did not always provide you with the right conditions to do your jobs as you would wish and we take responsibility for that.

"At Nottingham University Hospitals, we are determined to provide maternity services that are consistently safe, compassionate, equitable and responsive. We want every family to have confidence in the care they receive. We want to reassure anyone using our services today that you will be safe in our care.

"On behalf of the trust, we renew the commitments to transparency, openness and accountability. Most importantly, we renew our commitment to providing safe, high-quality maternity care at your hospitals."

Ockenden continues: "We owe it to every mother and baby whose terrible experiences are recorded to be sure the failures here are never repeated.

"Time for talking and reflecting has passed this need collective action, sustained action and renewed confidence.

"The families of Nottingham have shown extraordinary determination and courage in the face of devastating consequences which has marked their lives - they did this so what happened to them does not happen to anyone else."

Families and others gathered in the room then stood for a minute's silence, which marked the end of Ockenden's presentation.

Ockenden has told the room that the service at NUH now is "not where it was, but it is not yet where it needs to be".

She added: "The progress needs to sustained, deepened and built upon."

Ockenden has said junior staff at NUH were afraid to escalate concerns, and the incident review panel was "intimidating and male-dominated".

Bullying was "normalised", she added, and speaking up was described as "dangerous".

She added this was "not a reflection of all staff", but that the culture at NUH prioritised "institutional reputation over patient safety".

Staffing levels were the most serious and pressing issue raised, with only 11% reporting sufficient staff for the workload.

All staff agreed senior and executive managers have either ignored or been unable to respond to concerns raised over the years.

The review says there was a "bullying and toxic culture", which was a "long-running theme" in NUH's maternity services.

More than "40% had either witnessed or personally experienced bullying by managers or other colleagues" as a regular part of their working environment.

Some staff were consistently mentioned as forming "intimidating cliques" that are/were well-known but were "never confronted or challenged".

Ockenden continues to speak about post-death care.

She said: "Inpatient care does not end and must continue when a patient dies. The way in which our dead are treated is a mark of a civilised society.

"Concerns were raised directly with review by families when there are shortcomings their dignity can be significantly impacted - all cases reviews involved a loss of dignity."

Due to "particularly distressing evidence" uncovered relating to the post-death care of Harriet Hawkins, who was stillborn in 2016, it was agreed a full review into the quality and safety of post-death care would take place.

According to Ockenden's review, this comprised the care of 17 babies and one adult who died.

The report said: "The review found evidence of recurring examples of failure to protect the dignity of the deceased, including an early gestation baby disposed as clinical waste; dehumanising language by clinicians; poor mortuary care, including failure to comply with legal requirements and inadequate arrangements for undertaking paediatric post-mortems."

Warning: This post contains details that some may find distressing

In reference to post-death care, Ockenden said a "very serious incident" occurred in 2022, involving the release of the wrong baby to a funeral director.

"Fortunately, the error was identified by the mortuary staff during a 'long stay patient check', before the 'wrong' baby was buried or cremated in the other baby’s place, and the baby who had been released incorrectly was returned to the mortuary," the report added.

Ockenden has said there were an additional 533 families whose cases fell outside the terms of reference of her review who came forward to share their experiences.

"They too have been heard," she added.

Sarah Hawley
East Midlands Today

Many families are nodding in agreement at points during Donna Ockenden's speech, as she outlines the lack of bereavement care. Some are in tears.

Ockenden has also praised MPs for supporting constituents who have been affected by maternity failings, and the journalists who took up their stories.

On NHS regulators, the senior midwife has said there was an "erosion of trust of midwives and doctors for the families".

She added: "Families said they were knocking on a closed door and faced a brick wall - they spent years trying to be heard while poor practice continued."

Continuing to address the room, Ockenden said: "This report is about what happens when leadership fails, when government fails... bullying tolerated and concerns are repressed, incidents downgraded and the voice of women, particularly the most vulnerable, are systemically dismissed.

"This is a report about how a system failed and what it costs when it fails. It cost lives, futures and families, everything."

Ockenden tells the room that "failure to investigate and failure to learn are hauntingly consistent".

Echoing lines in her report, she said: "This review owes it very existence to a group of families who refused to be silenced - they came together in harm and in grief - united in their determination to what had happened to them should not happen to anyone else.

"Without these families, Nottingham may still be experiencing these tragedies."

Many of the problems detailed in the report have been known about at the trust since "at least 2010", Ockenden said.

These include insufficient staffing, and the inability of staff to carry out basic and often mandatory training. She also highlighted a "persistent failure to listen to and believe mothers and fathers" - as well as a failure to investigate, and therefore learn from, mistakes.

Ockenden also highlights a "startling statistic", that says clinical negligence is costing the NHS almost the same in legal compensation - as it spends on the delivery of maternity care itself.

Donna Ockenden is now addressing a room filled with families and press.

She said: "We did not want to have to write this report, this is something the families of Nottingham should never have needed.

"This report had to be written - what happened here cannot be allowed to remain in the shadows.

"The families deserve at the very least the truth."