King's College London

Dr Rebecca Whybrow, Lecturer in Midwifery, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care

"The Nottingham NHS Trust review led by Donna Ockenden is extremely distressing. Women and babies have suffered unacceptable harm. Failures in leadership and governance at the Trust have resulted in systemic unsafe care over that has persisted over two decades. Women repeatedly reported not being listened to, their concerns were not escalated, and they were unable to make decisions about their pregnancy and birth resulting in substantial harm to women and their babies. It is essential that women’s human rights in childbirth are upheld underpinned by being listened to and making supported decisions about their care. This requires widespread training of maternity staff across the NHS, alongside improvements to leadership culture that places the human rights and experiences of women first. Leadership across England’s NHS maternity services should be evaluated with evidenced-based programmes embedded to address gaps.

It is also clear more multi-professional training is required in many areas of maternity services from the management of postpartum haemorrhage, fetal monitoring, and neonatal life support. The national core competency framework has been in place since 2020 however the extent to which it is consistently delivered across England is being evaluated presently.

Leadership evaluation and improvements are needed across England’s maternity services. Alongside this evidenced-based training in both humanised care and clinical competence must be delivered to all professionals working in maternity with consistency to ensure women are always provided safe care, are listened to and supported to make decisions about their care."

Dr Claire Feeley, Senior Lecturer in Midwifery, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care

"Donna Ockenden's review into Nottingham maternity services sheds an important light on multiple systemic failings, that together, demonstrated how far too many families were harmed, that was significantly compounded by being ignored. It is vital that local services, listen, hear, learn and act upon their local population's needs which can only be achieved by direct and meaningful engagement with their communities. I welcome the Immediate Essential Actions as national lessons for all Trusts. Among the 18, while all important, re-introducing continuity of carer especially for vulnerable families, committing to robust workforce planning and funding, and emphasising the need for postnatal wards to be staffed where babies are included in the head count would see immediate improvements for women, birthing people, their partners and babies."

Dr Hannah Rayment-Jones, a midwife and Advanced NIHR Research Fellow in the Faculty of Life Sciences and Medicine

“The findings of the Ockenden Review are deeply distressing and our thoughts are with the women, babies and families who have experienced harm and loss. The review highlights the devastating consequences when women are not listened to and also draws attention to the persistent inequalities experienced by women facing social disadvantage.

These findings reflect our research at King's College London, which has consistently shown poorer maternal and infant outcomes among women experiencing poverty, social vulnerability, migration-related challenges and other forms of disadvantage. The report's recommendations around continuity of care for women with additional medical or social complexities are particularly welcome, but reducing inequalities will require action not only within maternity services, but also on the wider social and policy factors that shape women's health before, during and after pregnancy.”

Professor Jane Sandall, Professor of Social Science and Women's Health in the Faculty of Life Sciences and Medicine

“My heart goes out to the families whose poor care are laid out in great detail in this thorough investigation and review. It also goes out to the staff who tried to raise concerns and were not listened to. Sadly, it reflects our research findings from a range of projects since 2010 about women and families concerns about their care and safety. Including developing an animation with Tommy’s to provide women with support to raise concerns and of what good looks like for women, families, frontline staff and organisational learning when harm happens in maternity care. I welcome the focus on health system harm and await to see how this report affects change.”

Dr Cristina Fernandez Turienzo a Senior Research Fellow in the Faculty of Life Sciences and Medicine

"My thoughts are with all the women, babies and families affected. The report highlights what happens when a whole system fails to provide safe, compassionate and equitable maternity care, and sadly, many of the issues identified will not be new to those familiar with maternity services. This can't be just another review, and we need to learn from persistent failings. I welcome Martha’s Rule in maternity and wider health system solutions that consistently support women and families at every stage of their care. Much of our research has shown that continuity of care can help women and families at the highest risk of poor outcomes, improve trust in the system, provide a vital safety net, and contribute to reduce inequalities''.

Dr Kaat De Backer, a midwife research fellow in the Faculty of Life Sciences and Medicine

"My thoughts are with the many families at the heart of the review, who were harmed, let down, and dismissed in the most appalling ways. I want to commend them for their continued campaigning, strength and dignity, to seek justice not just for themselves, but for other families affected by these issues.

The report is a difficult read and painfully exposes how a systemic culture of toxicity, bullying and dismissive attitudes towards pregnant women and birthing people is detrimental to both compassionate, high quality patient care, as well as a safe and supportive environment for staff who aim to provide such care.

While the review has called out these unacceptable behaviours and attitudes, it has also highlighted how many staff tried to provide good, compassionate care, in the most challenging circumstances, amidst continued staff shortages, inconsistent leadership and acuity pressures. It is important to acknowledge this, and I applaud the staff who tried to raise their concerns and took part in the review.

There is no single solution to address the many issues highlighted in the review, yet we welcome the recommendations about safe, personalised, and equitable maternity care, with continuity of care available to all women, in particular for those with additional complexity. In addition, the recognition of safe staffing is critical to provide high quality care to women and their families, at every step of the pregnancy and postnatal care. However, we cannot expect maternity services to improve without adequate, ringfenced investment. An overhaul of the chronic underinvestment in maternity care is needed to make sure every woman, baby and family has the best care and support at this important time of their life."