It has been confirmed that the independent review into Nottingham maternity services after hundreds of baby deaths and injuries across the city, has been expanded to include 300 more families.
Largest review in NHS history
The review, which was already the biggest in NHS history, was launched in 2022 after years of campaigning by families affected by care and treatment received at Nottingham University Hospitals NHS Trust (the Trust) maternity services.
Expert midwife, Donna Ockenden, along with other healthcare professionals are tasked with conducting the review and have already spent thousands of hours speaking with families and reviewing relevant records.
Expanding the review
On 1 February 2025, Ms Ockenden issued an update.
She confirmed that the review was being expanded to include 300 new families. She said:
“As of today, 2,032 families have joined the review.”
The expansion of the review and the addition of so many new families means that the publication of the report will be delayed from 2025 to June 2026.
Discrepancies
Speaking of the significant number of further families to be included in the review, Ms Ockenden said:
“We have been working with Anthony May, Chief Executive of Nottingham University Hospitals NHS Trust, and his colleagues to ensure that all appropriate cases are included in the independent review. This work has identified some discrepancies. These discrepancies are cases that should have been provided to the review but were not.”
The discrepancies relate to the following categories of cases:
- Babies who have died
- Babies with brain injury
- Mothers who have died
Ms Ockenden further commented:
“We would like to stress that this has arisen from a genuine misunderstanding. As a matter of urgency, these cases will be sent to the Review Team…
As a result, the number of families that are to be included in the review will significantly increase. This is expected to be up to 300 new families. We expect that the numbers of families in the review (when the review closes to new cases at the end of May 2025) to be about 2,500 families.”
Delays
As a result of the significant expansion of the review, there will be delays in the publishing of the review report.
Originally expected by September 2025, Ms Ockenden has now said:
“With the new families joining the review we are letting you know we will have to delay publication of the report until June 2026, with family feedback to follow after publication. This will give the review team the opportunity to provide support to all families and allow for all cases to be reviewed to the highest professional standards that all of us expect.”
She also added:
“We recognise that this update may be difficult for some families to hear, so if you feel as though you need extra support at this time, please contact the Review team, or the Family Psychological Support Service…We are here to help you wherever we can.”
Maximising learning
Chief Executive of the Trust, Anthony May, said:
“It is important that we use the review to maximise leaning and that all affected women and families are included.
I fully support the decision to include new families, and I support the decision to extend the timetable. Since the start of the review, we have worked closely with Donna Ockenden and her team, and this will continue through to the report’s publication and beyond.
While the review is ongoing, we will continue to do everything we can to improve our maternity services further. It is clear that, thanks to a huge amount of work from colleagues in the service, we have achieved sustainable and evidenced improvements in our maternity services.
Women, families, and the communities we serve can be assured that our maternity services are better now than they were at the start of the review.”
Comment
The extent and scope of this review should not be underestimated.
Over 2,000 families already involved after potentially experiencing issues with care and treatment provided to them by the Trust’s maternity services shows how vast the problems were within the Trust.
The outcome of this report is going to be a significant moment. The delays in its publication will clearly be upsetting for families and they are bound to be concerned about when this will all end. However, it is vital that all who have been affected can have their cases considered and heard.
Whilst it is reassuring that the Trust are working hard to make the necessary changes, that certainly does not alter the fact that there were clearly deep-rooted problems within the service for a long time and that this resulted in potentially avoidable harm to mothers, babies, and their families.
It is the very least those families deserve to know that, by speaking up and finding the bravery to take part in this review, lessons are finally being learned, and changes are being made.
There remains so much work to be done by the Trust to continue to improve and to rebuild respect and trust with those who will need and use the service in the future.
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