I watched the episode of Panorama last night (1 June 2026) hoping to go away with a feeling that lessons had been learned and that the tragedies which occurred at Nottingham University Hospitals NHS Trust (NUH) which gave rise to the review into the maternity services (Ockenden Maternity Review – Ockenden Review), could never occur again. Unfortunately, I was left feeling that the events in Nottingham are far from unique and that the present system places too much reliance on failing maternity services to identify and report their own failings.
Nature can be cruel and complications in pregnancy and childbirth can mean even with the best care, babies and mothers die. These are tragedies.
But there is nothing worse than discovering that the death of your baby could have been avoided, with better care. My concern is that the spotlight being shone on NUH has not come about as a result of robust internal mechanisms or self-reflection by the Trust but rather because families have fought back against the narrative being given by NUH. Despite being told that the deaths of their babies were just bad luck, that they were isolated incidents and that the deaths of their babies were “one offs”, the families did not accept this. This has eventually given rise to Donna Ockenden’s review into Maternity Services at NUH involving 2,500 families who received maternity care between 2012-2025. But it seems to me that this never would have happened had it been left to the Trust.
The Panorama document highlights
It references cases involving failures to recognise placental abruption, obstruction, infection and failing to escalate concerning CTG monitoring.
It paints a picture of a bullying culture where midwives were fearful of escalating matters to senior midwives or doctors, where staff were unsympathetic and uncaring of the women in their care (listing women on a board with the letters FOH meaning F*** off home) and where the Trust was consistently miscalculating the number of midwives required to deliver safe maternity care, meaning that they were significantly understaffed.
All of this is terrible and truly shocking but what concerns me is what happened after these tragedies occurred.
An NHS maternity trust must refer a case when a baby:
- (37 weeks +) passes away during labour but before birth;
- dies in the first week of life,
- suffers severe brain injury; or
- where a mother dies within 42 days of the birth
to the Maternity and Newborn Safety Investigation (MNSI) Program.
Donna Ockenden in the Panorama documentary indicated that many cases which should have been referred externally were not. It is her view that this was to avoid scrutiny and it is hard to see any other reason for this failure.
During internal investigations into stillbirths and neonatal deaths, NUH categorised deaths of completely healthy babies as “expected”, preventing any scrutiny of the care provided or any opportunity for learning. The documentary also specifically highlighted that 3 babies died at the Trust following placental abruption within a period of only 14 weeks. Given that placental abruption affects only 1% of pregnancies and that around 50% of these will be mild and not typically associated with a threat to life for mother or baby. So many fatal incidents should have raised alarm bells and caused the Trust itself to change its practices.
It is clear from the Panorama documentary that the senior leadership team at Nottingham University Hospitals NHS Trust knew maternity services at the Trust were not good enough. But rather than take steps to address the issues within maternity services, they instead sought to cover up the events. The entire leadership team has been replaced and Anthony May was appointed as Chief Executive of the Trust in 2022. It appears that he is offering more transparency and openness when things go wrong. However, it is not clear to me the extent that the change of leadership has yet had a material impact on the care being provided at the Trust and I note that the inquiry into maternity services at Nottingham includes births up to 2025.
This is the 4th inquiry into maternity services care provided at NUH since 2013. Despite the millions of pounds spent, the issues highlighted in these reports and the recommendations made still
- 4,477 babies died as a result of stillbirth or neonatal death in 2024
- there has been a 20% increase in maternal deaths in the past 15 years; and
- black women remain three times more likely to die as a result of childbirth than white women in the UK.
It seems to me that we cannot rely on failing maternity units to hold themselves up to scrutiny by trusting them to refer cases of their own volition. Instead we need a robust external mechanism to force scrutiny on failing services.
Panorama – Maternity Failures: The Fight for Justice – BBC iPlayer
Reporting for Panorama, Michael Buchanan hears powerful testimonies: from mothers who weren’t listened to, staff who blew the whistle but were ignored, and from parents whose babies’ tragic deaths were dismissed as ‘just bad luck’. The programme also hears from the new chief executive of the Nottingham University Hospitals NHS Trust, who has promised change.
https://www.bbc.co.uk/iplayer/episode/m002xk5r/panorama-maternity-failures-the-fight-for-justice