The Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust (NUH), led by Donna Ockenden, published its findings on 24 June. Covering care provided to more than 2,000 families between 2012 and 2025, it is the largest maternity inquiry in NHS history, and found that 22% of maternity cases examined showed significant or major concerns in care.
The Review found these clinical failings sat within a wider pattern of leadership instability and governance failure. Between 2015 and 2022, NUH commissioned six external reviews into maternity culture and governance – all critical, none leading to sustained change. Board members were not consistently given visibility of significant issues, and midwifery leaders lacked direct access to the Board, creating, in the Review’s words, “disconnect between strategic direction and operational management.”
This was compounded by leadership turnover: NUH had five Directors of Midwifery between 2017 and 2021 alone, including three interim appointments within six months. Staff were frequently promoted into senior roles without induction or mentoring, and the Review found “a lack of structured leadership development,” leaving leaders “unprepared when managing conflict, supporting team wellbeing, or cultivating a positive organisational culture.”
Between 38% and 44% of staff reported witnessing or experiencing bullying, and the Trust’s Freedom to Speak Up function did not operate effectively for much of the period reviewed; staff who raised concerns described facing victimisation as a result.
The Review notes a clear change since 2022, with a new Chief Executive, Chair and permanent Director of Midwifery, a maternity-specific Freedom to Speak Up Guardian, and quarterly Listening Forums. The most recent CQC inspection, published in 2026, recognised this progress while noting further work is needed to embed it.
Actions
The Review sets out 22 Immediate and Essential Actions across eight areas, including workforce planning, listening to women and families, and governance and Board accountability. Other recommendations include a Board-level maternity subject-matter specialist in every Trust, protected time for governance and learning, and a requirement for Trusts to actively foster psychological safety so staff can raise concerns without fear of reprisal.
The Government has responded with a commitment to roll out Martha’s Rule, the landmark patient safety initiative, to all maternity settings in England.
Prof Greta Westwood CBE RN, CEO of the Florence Nightingale Foundation, said:
“Our first thoughts are with every family whose experience is reflected in this report. We thank them for their courage and persistence in coming forward.
What this Review describes is a service that, for too long, lacked stable and visible leadership – where people were promoted into senior roles without the mentorship or development to support them, and where staff did not always feel safe to speak up.
We know the difference that leadership development can have on maternity service users, patients, families, and communities. We agree with the Review’s conclusions that leadership development for midwifery and neonatal staff at all levels must be part of the solution moving forward. The Florence Nightingale Foundation remains committed to working with all maternity services to build the confident, well-supported nursing and midwifery leadership that safe care depends on.”
