Quick Answer
The final report from the Ockenden Review, published on 24 June 2026, found serious and longstanding failures in maternity and neonatal care at Nottingham University Hospitals NHS Trust. Based on more than 2,500 family cases, it found problems including women and families not being listened to, missed signs that a woman or baby was becoming more unwell, and failures to learn when things went wrong.
But Nottingham is not the whole story. Other investigations have raised similar concerns about maternity care across England. For me, this raises a much bigger question: what does good maternity care actually look like, and why is listening to women such an important part of making care safer?
As a mother and the founder of Lola&Lykke, this is a subject that is deeply personal to me. My own experiences of pregnancy, birth and loss have shaped the way I think about maternity care and, in particular, what it means for women to feel heard.
But before we can ask what good maternity care should look like, we need to understand what the Ockenden Review found, and why its findings matter far beyond Nottingham.
Contents
- What is the Ockenden Review?
- What did the Ockenden Review find?
- Is this just a problem in Nottingham?
- What did the 2026 national maternity and neonatal investigation find?
- Why does listening to women matter?
- Listening is also about giving women a voice in decisions
- What is changing in NHS maternity care following the reviews?
- What is Martha's Rule?
- What is the Maternity and Neonatal 10 Point Plan?
- What can I do if I don't feel heard?
- What should good maternity care look like?
- Maternal care shouldn’t end at birth
- FAQs
What Is the Ockenden Review?
The Ockenden Review is an independent investigation into maternity and neonatal care at Nottingham University Hospitals NHS Trust (NUH). Led by senior midwife Donna Ockenden, it was commissioned in 2022 after families affected by maternity services at the trust raised serious concerns about an existing review and called for a new, independent investigation.
The review began with families who had experienced harm and bereavement and did not feel that the existing process was giving them the answers or accountability they needed. In April 2022, more than 100 people from affected families wrote to the then Health Secretary, Sajid Javid, asking for the existing NHS England review to be closed and replaced by an independent review led by Donna Ockenden.
That happened, and the review grew significantly over the next three years. By the time its final report was published in June 2026, it was based on more than 2,500 family cases, mostly relating to care provided between 2012 and 2025.
This was a huge undertaking. More than 160 reviewers from different healthcare professions worked on the investigation. The review team met individually with more than 500 families, and more than 830 current and former NUH staff also took part.
The aim was not simply to look back at what had happened. It was to understand:
- Why things had gone wrong.
- Why problems had been allowed to continue.
- What needed to change to make maternity and neonatal care safer.
What Did the Ockenden Review Find?
The findings make difficult reading. The review found serious problems with maternity and neonatal care, including women and families not being listened to, signs of women and babies becoming more unwell being missed, failures to learn when things went wrong and wider problems with staffing, training, leadership and workplace culture.
Several themes appear again and again.
1. Were Women and Families Listened To?
Not always. The review found that women's and families' concerns could be dismissed or not acted on.
This wasn't simply about whether somebody felt listened to. In maternity care, listening can be a matter of safety. If a woman says something has changed or doesn't feel right, taking that concern seriously can be an important part of recognising when she or her baby needs more help.
2. Were Signs That Someone Was Becoming More Unwell Always Recognised?
No. The review found missed opportunities to recognise when women and babies were becoming more unwell, and problems with how concerns were assessed, monitored and passed on when more urgent help was needed.
The language used in clinical reports is often ‘recognising deterioration’. Put simply, it means noticing that a woman or baby's condition is getting worse and responding quickly enough.
3. Did the Service Learn When Things Went Wrong?
Not consistently. The review found weaknesses in the way incidents and concerns were investigated and in how lessons were then used to improve care.
Investigating what happened is only useful if something changes afterwards. If the same problems continue, other women and families can face the same risks.
4. What Did the Review Say About Staffing and Training?
The review also found problems with staffing and staff training, including difficulties allowing staff to complete the training they needed.
Having enough appropriately trained staff is a basic part of safe maternity care. Staff also need the time, support and working environment to use that training properly.
5. Were Staff Able to Speak Up?
The review raised concerns about whether staff felt able to speak up when they believed something was wrong.
Women and families need to be heard, but so do the professionals caring for them. A safe service needs staff to feel able to question a decision or raise a concern without being afraid to do so.
Is This Just a Problem in Nottingham?
Unfortunately, no. The Ockenden Review looked specifically at Nottingham, but other investigations have found worrying problems elsewhere in England.
When the Care Quality Commission (CQC) looked specifically at maternity safety, 47% of the services it inspected were rated ‘requires improvement’ and 18% were rated ‘inadequate’. None received an ‘outstanding’ rating for safety.
The CQC found recurring problems with maternity triage, recognising when women and babies were becoming more unwell, staffing, communication and learning from safety incidents. Perhaps most concerning is that many of these problems were not new.
Then, just six days after the final Ockenden Review report was published, another major investigation looked at the wider picture across England.
What Did the 2026 National Maternity and Neonatal Investigation Find?
Baroness Valerie Amos's Independent National Maternity and Neonatal Investigation was separate from the Ockenden Review. Its final report was published on 30 June 2026 after looking at maternity and neonatal services more widely across England.
The investigation included reviews at 12 NHS trusts and heard from women, families and NHS staff.
It made eight national recommendations for longer-term change:
- Create a national Maternity and Neonatal Commissioner.
- Listen systematically to women and families.
- Improve the way services respond when something goes wrong.
- Introduce clear national standards for high-quality maternity and neonatal care.
- Tackle racism, discrimination and inequality.
- Strengthen accountability and oversight.
- Improve culture, teamwork and leadership.
- Make sure maternity services have the buildings and digital systems they need.
Some of those recommendations are about how the NHS operates behind the scenes. But others go straight to the heart of what women experience when they receive maternity care. Once again, listening to women and families is right there on the list.
These are separate investigations looking at different services, yet we keep coming back to some of the same issues: women not being heard, poor communication, inequalities in care and a system that doesn't always learn when something goes wrong.
Why Does Listening to Women Matter?
There is a phrase that appears again and again in reviews of maternity care: we need to listen to women.
It sounds almost painfully obvious. And yet the fact that it continues to appear across Ockenden, CQC investigations and review after review tells us something important. Listening to women isn't simply about making maternity care kinder or more compassionate. It is part of making maternity care safe.
Across the 2,500 family cases reviewed by Ockenden, women described concerns being minimised, symptoms being dismissed and instincts being reframed as anxiety. Some women said that repeated changes of midwife meant important information was missed or not documented properly. Others described having to repeatedly justify why they needed to be assessed.
Women also bring something essential to their care: knowledge of their own bodies.
That doesn't mean a woman should be expected to diagnose herself, or that clinical expertise becomes less important. When a woman says something doesn't feel right, that information should form part of the clinical picture and not be treated as an inconvenience.
I understand this on a very personal level. After my first baby was born, I experienced significant complications, but I largely accepted what happened. I thought: this is incredibly hard, but I suppose this is just what having a baby is like. It was only after losing my second baby later in pregnancy following similar complications that I began to question that assumption.
By my third pregnancy, I approached maternity care very differently. I asked more questions, challenged decisions and advocated strongly for myself. But that experience left me with another question: why should a woman have to become an expert and advocate for herself to feel safe?
Not every woman feels able to challenge a healthcare professional. Not everyone has the knowledge, confidence, language skills or emotional capacity to keep asking questions when they feel something isn't right. Pregnancy and birth are already intensely vulnerable experiences. The safety of your care should not depend on how assertively you can make yourself heard. And we know that disparities in maternal experiences and outcomes mean some women's voices are less likely to be heard than others.
This is one of the reasons I have always felt so strongly that mothers must be treated as intelligent individuals. Women know themselves. They know their bodies, their circumstances, their fears and their limits. Good healthcare brings that knowledge together with clinical expertise rather than placing one above the other.
Listening Is Also About Giving Women a Voice
Being listened to goes beyond responding when something is wrong. It means giving women the information they need to take an active role in decisions about their own care.
A consent form on its own doesn't create informed choice. Women need to:
- Understand what is happening.
- Have the risks and alternatives explained honestly.
- Have time to ask questions where circumstances permit.
- Know that their own preferences and values are being taken into account.
A woman shouldn't have to start from scratch every time she meets a new midwife or doctor. Her history, previous complications, concerns and agreed care plan need to travel with her. Ockenden heard directly from women who felt that constantly seeing different midwives meant information was missed, misunderstood or simply never recorded.
When communication breaks down between professionals, the woman herself can end up having to hold all the pieces together. That is an enormous responsibility to place on someone who may be in pain, frightened, exhausted or in labour.
What Is Changing in NHS Maternity Care Following the Reviews?
There is a lot in these reports that is upsetting. But there are also changes being made now.
Two that are particularly relevant to women and families are Martha's Rule and changes being introduced through the NHS Maternity and Neonatal 10 Point Plan.
What Is Martha's Rule?
Martha's Rule is being introduced across maternity settings in England. If a woman or her family is worried that she or her baby is becoming more unwell and they don't feel their concerns are being acted on, it gives them another way to ask for an urgent review by a different medical team.
The Ockenden Review showed how important it is for women and families to be heard when they believe something is wrong. When concerns are dismissed or not acted on quickly enough, opportunities to prevent harm can be missed.
What Is the Maternity and Neonatal 10 Point Plan?
NHS England announced a Maternity and Neonatal 10 Point Plan following the Ockenden and Amos reports.
Some parts of the plan are about how NHS trusts are managed and held accountable, but there are several parts that could make a noticeable difference to women and families. These include:
- Listening to women and families and using their experiences to improve care.
- Tackling inequalities in maternity and neonatal outcomes.
- Making sure services are safe and responsive 24 hours a day, seven days a week.
- Improving maternity triage, so women who contact or arrive at maternity services with an urgent concern are assessed and prioritised safely.
- Responding to safety incidents, complaints and concerns openly and honestly.
- Introducing Martha's Rule across maternity and neonatal services.
A broader national action plan is also being developed through the National Maternity and Neonatal Taskforce.
What Can I Do if I Don't Feel Heard?
First, I want to be clear about something: it should not be a woman's job to make maternity care safe.
You should not come away from reports like Ockenden believing that avoiding harm depends on how loudly or persistently you advocate for yourself. However, you should feel able to ask questions, say when something doesn't feel right and ask for more help if you remain worried.
Some practical things you can do are:
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Tell someone what you're worried about. Explain what has changed or feels different if you can. If you can't explain exactly what's wrong, you can still say that something doesn't feel right.
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Ask questions. If you don't understand what you're being told, ask for it to be explained again. You can also ask for more information about what is being recommended and why.
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Ask what happens next. Find out when you or your baby will be checked again and what changes would mean you need further help.
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Ask for someone else to review your concerns. If you still don't feel heard, ask who else you can speak to or whether a more senior member of the team can review you.
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Ask your birth partner or supporter to help. If you want them to, they can explain what they've noticed, ask questions and help make sure your concerns are understood.
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Ask about Martha's Rule if you or your baby is becoming more unwell. Where it is available, you can ask for an urgent review by a different clinical team if you don't feel concerns about a worsening condition are being acted on.
Each hospital operating Martha's Rule has its own contact number. You may find it on the hospital's website or on posters in the hospital, or you can ask a member of staff. There is no single national Martha's Rule number.
Martha's Rule is not yet available in every maternity setting, although the government has announced that it will be introduced across maternity services in England. If you're unsure whether it is available where you're receiving care, ask your maternity team or check your hospital's website.
If Martha's Rule isn't available and you're worried that you or your baby is becoming more unwell, don't wait for it. Tell the healthcare team that you're concerned and ask what other options are available for getting your concerns reviewed. If you are in hospital and are having difficulty getting an urgent concern addressed, you can also ask to speak to the hospital's Patient Advice and Liaison Service (PALS). PALS is not a substitute for an urgent clinical review.
What Should Good Maternity Care Look Like?
For me, good maternity care comes back to something very simple: see the woman in front of you as an individual. Not another pregnancy. Not another bed. Not another set of observations on a chart. A person.
Good maternity care combines clinical expertise with the woman's own knowledge of herself. It provides continuity, so concerns don't disappear between appointments. Professionals communicate with each other. Women are given explanations rather than instructions, and questioning care feels normal rather than confrontational. It also recognises that every woman is different and may need different types and levels of support.
Ultimately, women should feel able to ask questions, know that their concerns will be taken seriously and be active participants in decisions about their bodies and their babies, rather than passive recipients of care.
Maternal Care Shouldn’t End at Birth
For me, there is also a wider conversation about where maternal healthcare begins and ends.
Pregnancy, birth, postpartum recovery, breastfeeding, and eventually returning to everyday and working life are not isolated events. They are connected parts of women's maternal health. Yet too often our systems treat them as separate episodes, and the support available to women drops away dramatically once the immediate clinical event has passed.
That was a huge part of why I founded Lola&Lykke. My own experiences of complicated pregnancy, birth and loss made me realise how easily women can become a category within a healthcare system rather than being seen as individuals. After my first birth, I accepted many of the difficulties I experienced as simply part of becoming a mother. After losing my second baby following similar complications, I began to see things very differently.
I also realised that the gaps in support don't end at birth. Once the baby arrives, the focus shifts incredibly quickly to the child, while the mother may be navigating physical recovery, feeding difficulties, sleep deprivation, emotional upheaval and eventually the enormous transition back into working life, often with remarkably little structured support.
This is the space Lola&Lykke was created to work in. Not to tell women what they should do, but to give them better information, better tools and better support so they can make the decisions that are right for their own bodies, babies and circumstances.
The Ockenden Review rightly focuses attention on where maternity care has gone terribly wrong. Now we need to prevent those failures from happening again, while also asking what genuinely good maternal healthcare should look like.
For me, the starting point is simple: see the woman, listen to her and support her as an individual throughout pregnancy, birth and beyond, not only until her baby is born.
Healthcare is, of course, vastly more complex than that. Clinicians make difficult decisions, sometimes under extraordinary pressure, and listening alone cannot solve staffing shortages, inadequate resources or wider problems within the system.
But perhaps that is precisely why the words ‘listen to women’ keep returning.
This isn't a call for maternity professionals just to be nicer. It is about women being taken seriously when they say something doesn't feel right, being given the information they need to make informed decisions, and knowing that the professionals caring for them are communicating with each other. Above all, every woman should feel able to raise a concern and know that somebody will listen.
After so many reviews, that should no longer be an aspiration.
It should be a basic standard of safe maternity care.
FAQs
When was the final report from the Ockenden Review published?
The final Ockenden Review into maternity services at Nottingham University Hospitals NHS Trust was published on 24 June 2026. It followed an independent investigation led by senior midwife Donna Ockenden and was based on more than 2,500 family cases.
Which hospitals did the Ockenden Review investigate?
The review investigated maternity services provided by Nottingham University Hospitals NHS Trust, including services at Nottingham City Hospital and Queen's Medical Centre.
How many families were included in the Ockenden Review?
The final report was based on more than 2,500 family cases.
What were the main problems identified by the Ockenden Review?
The review identified serious problems involving the safety and quality of maternity and neonatal care, including failures to listen to women and families, recognise deterioration and learn effectively from incidents, alongside wider concerns about staffing, training, leadership and culture.
Are maternity safety concerns limited to Nottingham?
No. The CQC's national maternity inspection programme found widespread safety concerns across England. Of the services inspected, 47% were rated ‘requires improvement’ for safety and 18% as inadequate.
What is Martha's Rule in maternity care?
Martha's Rule provides an additional way for patients and families to seek a rapid review when they are concerned that someone's condition is deteriorating. In June 2026, the Government announced that it would be extended to all maternity settings in England.
What happens next for maternity services in England?
NHS England has set out a Maternity and Neonatal 10 Point Plan in response to the Ockenden and Amos reports, while a wider national action plan is being developed to address longer-term systemic and cultural problems.
