The independent review examined the experiences of more than 2,500 families over a period of more than 10 years. 

 

It found that around one in five cases involved care that may have contributed to harm, including 260 babies whose outcomes may have been different with better treatment – 155 who died and 105 who suffered serious injury, sometimes with lifelong consequences. 

 

Thompsons Solicitors, which represents families affected by maternity failures, said the report shows longstanding concerns about leadership, staffing and patient safety remain unresolved across the NHS. 

 

The firm said the findings also highlight the pressures facing frontline NHS staff, with chronic workforce shortages and limited resources placing both patients and healthcare professionals at risk. 

 

Commenting on the report, Victoria Gofton, Head of Clinical Negligence at Thompsons Solicitors, said: 

 

"The publication of the Ockenden Report into maternity services at Nottingham University Hospitals NHS Trust is both devastating and deeply familiar. 

"This is not a story of isolated clinical errors, but of sustained failures in systems, leadership and culture. It sets out what happened over more than a decade despite repeated warnings from both families and staff. 

 

"The figures are particularly hard to ignore. For the families affected, these are not statistics. They are lives changed, permanently." 

 

Victoria said the report highlights failings that have featured repeatedly in maternity inquiries across England and mirrors the experiences of many of the families Thompsons represents. 

 

"Women's concerns were too often not heard or acted upon, while opportunities to identify and respond to risk were missed within services operating under significant pressure. 

 

"The findings will be sadly familiar to many women and families. We have seen similar issues identified in Morecambe Bay, Shrewsbury and Telford, and East Kent. 

"That frustration is something we hear regularly from families. Many come to us having raised concerns at the time – sometimes repeatedly – and still feeling that something went wrong that should have been avoided. 

"At the same time, the report makes clear that many staff were working under severe pressure, with staffing shortages limiting the time and support available to provide safe care. Many midwives had raised concerns themselves. 

"The concern is not that these issues are new, but that they continue to persist across the system." 

 

She added that the report underlines the need for sustained national action to improve maternity care. 

 

"Ultimately, safe maternity care depends on the fundamentals being in place: enough staff with the time to care safely; systems that support early recognition and escalation; leadership that responds when concerns are raised; and a culture where women feel heard and treated with respect. 

 

"These are the foundations of safe maternity care. They cannot be delivered by individual Trusts alone. They require national attention, proper resourcing and meaningful oversight." 

 

With Baroness Amos's national maternity inquiry due to report next week, Victoria said there is an opportunity to address the wider challenges affecting maternity services across England. 

 

"With Baroness Amos's national maternity inquiry due next week, there is an opportunity to look beyond individual Trusts and address the wider challenges facing maternity services across England. 

 

"For the families affected, the priority now is action – not simply recognising what went wrong, but delivering meaningful and lasting change. 

 

"Without that, there is a real risk that the failures identified in Nottingham will be repeated elsewhere, with more families paying the price."