By GB News (World News) | Created at 2026-06-24 17:00:47 | Updated at 2026-06-24 18:05:34
1 hour ago
The deadly mistakes uncovered in the biggest maternity scandal in NHS history are being repeated across the NHS, one of Britain's leading maternity experts has warned.
As Donna Ockenden published her landmark 13-year review into Nottingham University Hospitals NHS Trust today, Professor James Walker, former maternity advisor to the National Patient Safety Agency, said the most striking finding was that Nottingham does not appear to be an outlier.
The former director of maternity investigations for the Healthcare Safety Investigation Branch said the review points to an "unacceptable background level" of avoidable harm across maternity services in England.
And he warned that babies will continue to die or suffer life-changing injuries unless ministers stop commissioning inquiries and start making sure lessons are implemented.
"The problem is that nobody has taken responsibility for proper implementation of change," said Professor Walker, of the University of Leeds.
The Nottingham review is the largest investigation into maternity services in NHS history, examining the care of more than 2,500 families. The 401-page document concluded 444 women and 76 newborn babies suffered "potentially avoidable" outcomes because they received substandard treatment over 13 years from Nottingham University hospitals NHS trust.
It found "multiple" women experienced dangerously poor and sometimes "cruel" care, understaffing was routine, lessons from patient safety incidents were not learned and bullying by "intimidating cliques" of staff was rife.
Women and families were repeatedly not listened to, warning signs were missed, staff shortages left services operating in "crisis mode" and a culture of bullying and hierarchy prevented staff from speaking up, it revealed.
Donna Ockenden published her landmark 13-year review into Nottingham University Hospitals NHS Trust today
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The review concluded failures were "deep-rooted, systemic and sustained over many years", with repeated missed opportunities to prevent harm.
Professor Walker stressed the inquiry was vitally important in giving bereaved and harmed families answers and acknowledging the suffering they endured, often after years of feeling ignored or dismissed.
But he believes the NHS must now move beyond investigations and focus on preventing the same failures from happening again.
He said: "The publication of today's Nottingham review marks a watershed moment as the fourth major independent investigation into NHS maternity services in more than two decades, following inquiries into Morecambe Bay, Shrewsbury and Telford and East Kent.
"The Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust is the largest of them all.
"That four such investigations have been necessary in twenty years is itself a measure of how deeply embedded the problems are."
Professor Walker said the figures buried within the report point to a much bigger national story.
Using the same grading system employed in national maternity safety investigations, he said around 21 per cent of maternity cases reviewed and six per cent of neonatal cases involved care where different management might have changed the outcome.
While any avoidable harm was unacceptable, he said those figures were consistent with a background level of harm seen across maternity services nationally.
He also noted that the figures were significantly lower than the 61 per cent rate identified by Ms Ockenden during her review of maternity services at Shrewsbury and Telford, published in 2022.
He said: "What it is highlighting is a background problem.
"It would appear that Nottingham is not an outlier."
He added: "If 20 per cent of maternal and child deaths are due to management which could have prevented it, that's unacceptable.
"There should be no acceptance of bad care."
Professor Walker said: "The figures are comparable with what national surveillance has repeatedly shown and which has consistently identified the same recurring themes: failure to recognise deterioration, inadequate risk assessment, poor escalation, and communication breakdown."
National safety data showed maternity care has failed to improve despite years of reviews and reform programmes
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He said national safety data showed maternity care had failed to improve despite years of reviews and reform programmes.
"Maternal deaths in the UK are now at a 20-year high," he said.
"Stillbirths, though reduced over the past decade, remain above pre-pandemic levels.
"A Government pledge made in 2015 to halve rates of stillbirth and neonatal death by 2025 was not met.
"The evidence is unambiguous: the background level of avoidable harm is a national problem, not a Nottingham problem."
He also pointed to the soaring cost of maternity negligence claims, which now account for around £2.5billion of the NHS's annual £4.9billion negligence bill — approaching the total cost of providing maternity care itself.
His comments are likely to fuel fears that, despite a succession of major maternity scandals, many of the same mistakes continue to be repeated.
Investigations into maternity services at Morecambe Bay, Shrewsbury and Telford and East Kent all uncovered failures to listen to mothers, poor communication, missed warning signs and weaknesses in leadership and safety systems.
Professor Walker said the Nottingham review reached strikingly similar conclusions.
It found failures to recognise deterioration in mothers and babies, weaknesses in risk assessment, communication failures and governance systems that repeatedly failed to learn lessons from previous incidents.
"Maternity care has a national problem and we've known about it, we've reported it, we've highlighted it, we've talked about it," he said.
He warned that another inquiry risks simply joining a growing pile of reports documenting the same failings.
His concerns were echoed by Kim Thomas, the chief executive of the Birth Trauma Association, who said: "Sadly, we believe that Nottingham is not unique. As a charity, we hear similar stories from hospitals throughout the country."
Prof Walker is now calling for the Government's new maternity taskforce to adopt an aviation-style approach to safety in a bid to stop the same tragedies happening again.
Under such a system, incidents would not simply be investigated before being filed away.
Instead, specialists would continuously analyse why failures occurred, identify weaknesses in systems and procedures, oversee reforms and ensure improvements are maintained for years afterwards.
Prof Walker is now calling for the Government's new maternity taskforce to adopt a new style of approach to safety in a bid to stop the same tragedies happening again
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Professor Walker said that is the crucial step the NHS has repeatedly failed to take.
"If you look at the airline industry, they have a constant review of events and improvement and change," he said.
"We have a constant review of cases, but we don't seem to actually do anything about consistently implementing change.
"That's the bit of the cycle that we don't do."
He believes a national body should be tasked with driving improvements across maternity services, helping trusts implement changes and ensuring lessons are not forgotten once public attention moves on.
But he said previous attempts had fallen short.
"The aviation model works because it is permanent, independent and has genuine authority to compel change rather than merely recommend it," he said.
"A taskforce that advises without power to enforce, or that operates for a fixed term before disbanding, risks becoming another entry in the long list of well-intentioned initiatives that did not hold."
He said any reform programme must involve policymakers, NHS managers, frontline clinicians and affected families.
"Families understand what went wrong better than almost anyone," he said.
"They need to be at the table when we're working out how to fix it."
The warning comes as ministers prepare a national maternity taskforce aimed at preventing future tragedies.
Health Secretary James Murray said the Nottingham review had exposed "serious systemic failures" and a "culture of silence" that contributed to harm.
He pledged that lessons from Nottingham would help shape a national plan to improve maternity and neonatal care.
The review itself set out urgent national actions covering staffing, training, investigations, governance, workplace culture and family involvement.
The Government has also pledged to roll out Martha’s Rule across maternity and neonatal wards in England which will allow every parent to request a rapid review from an independent medical team if a baby or mother’s condition is deteriorating and they are concerned this is not being responded to.
