Nottingham Review Statement
Written by Sian Ness, Bereavement Consultant and Midwife
Today marks the publication of the Nottingham maternity review, the largest investigation into maternity services in NHS history.
Over more than three years, Donna Ockenden and her team have listened to the experiences of around 2,500 families whose babies died, suffered serious harm, or whose own lives were forever changed by the care they received. The review has examined more than a decade of maternity care, looking not only at individual tragedies but at the systems, cultures and practices that allowed harm to occur and opportunities for learning to be missed.
Behind every finding, every recommendation and every page of this report are babies who were loved beyond measure and families whose lives will never be the same.
What strikes me most today is not the scale of the investigation, but the extraordinary courage of the families who made it possible. Many have had to relive the darkest days of their lives, repeatedly recounting moments of unimaginable trauma, heartbreak and loss to rooms full of strangers. They have spoken about the babies they loved the futures they imagined, and the devastating reality of living without them. They have revisited memories that no parent should ever have to carry, let alone repeat.
In my work as a midwife and bereavement consultant at CuddleCot, I recently had the privilege of meeting some of the Nottingham Families. Hearing these families speak about their babies has been both a privilege and a profound heartbreak. I have listened to parents describe losses that have shattered their worlds. I have witnessed the lifelong impact of grief, trauma and harm. I have met mothers and fathers carrying pain that words can barely capture.
What has stayed with me is that even in the depths of their own suffering, so many families remained focused on protecting future parents and babies. Their motivation has never simply been about what happened to them. It has been about ensuring that lessons are learned and that no family endures the same preventable tragedy.
This review is about justice for harmed and bereaved families. It is about accountability. It is about ensuring that the experiences of these families are acknowledged, understood and acted upon. Most importantly, it is about creating the urgent and necessary change required to make maternity care safer.
This report come after years of concerns raised about failures to listen to women, delays in recognising complications, poor communication, inadequate learning from incidents and wider cultural challenges within maternity services. Things I have witnessed myself.
These are not simply organisational failures.
They represent moments when families needed us most and were let down.
The findings are will be difficult to read, at times the content will be shocking. They will reveal not isolated incidents but deep and longstanding problems that have caused immeasurable harm. The scale of this investigation should serve as a wake-up call to everyone with responsibility for maternity services in this country.
Enough is enough.
It should never have taken thousands of families, countless harmed babies and bereaved parents, and years of campaigning for us to arrive at this point. There are simply too many families in this report. Too many babies who died. Too many opportunities missed to learn, to listen and to change.
This must be a turning point for maternity safety.
The response to this report cannot be more broken promises, delayed actions or carefully crafted statements. Every person with the power to influence maternity care must sit up, read these findings, listen to these families and act with urgency. The recommendations must not become another document that gathers dust. They must lead to measurable and lasting change.
Families deserve to feel heard.
Families deserve compassionate and kind care.
Families deserve to know that concerns will be taken seriously.
Families deserve safe maternity services.
We cannot ignore the impact this has had on staff. Across maternity services there are midwives, doctors, support workers and neonatal colleagues who feel broken, powerless and exhausted. Many have spent years trying to provide safe care within systems that are stretched beyond what should ever be considered acceptable. Despite this, they continue to show up for women, babies and families with compassion and commitment. They deserve better too.
They deserve to work in environments where they feel safe to speak up, challenge poor practice, raise concerns and advocate for women and babies without fear. The reality is that many staff are deeply affected by what they have witnessed and experienced. The systems they work within are often damaged and damaging.
Safe care cannot exist within unsafe cultures, and staff cannot continue carrying the burden of broken systems alone.
Today, however, belongs first and foremost to the families.
To every bereaved parent, every harmed family, every sibling, grandparent and loved one affected by the events described in this review: thank you. Thank you for your courage. Thank you for your persistence. Thank you for sharing your deepest grief, your most painful memories and your innermost thoughts. Thank you for refusing to allow your babies to be forgotten.
Your voices have changed maternity care forever.
I would also like to acknowledge Donna Ockenden and her entire team for their compassion, professionalism, commitment and unwavering dedication throughout this investigation. Their work has ensured that families were listened to with respect and dignity and that their experiences have been brought into the light.
The legacy of this review must not simply be a record of what went wrong.
It must be a commitment to what happens next.
For the babies whose lives were cut tragically short.
For the families who carry their loss every day.
For the staff who are truly broken, who at times feel helpless, yet continue every day to strive for safe, compassionate and respectful care.
And for every baby yet to be born.
We owe them nothing less.
The true legacy of this review will not be measured by the report itself, but by whether we have the courage to make sure no family has to contribute to another one like it.
If you require additional support at this time, please contact FPSS:
Email: enquiries@fpssnottingham.co.uk
Phone: 0115 200 1000
Or, you can access @conditionmanagement through our office:
Email: nottsreview@donnaockenden.com
Phone: 01243 786993