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Beyond the statistics: a birth injury lawyer's reflections on the Nottingham Ockenden Report
James Bell
After four years, the much-awaited government-commissioned independent review of maternity services at Nottingham University Hospitals NHS Trust has been completed and published here. Led by Donna Ockenden, the review was prompted by significant concerns about the quality and safety of maternity services at the Trust. The final report makes for damning reading, finding that a number of women and newborns suffered potentially avoidable harm or death. It also highlights toxic working conditions, allegations of cover ups, failures to escalate incidents and learn from mistakes. Ms Ockenden, a nurse, midwife and community activist, clearly states that: 'The culture of compounding of harm needs to stop!'
The report draws on more than 2,500 family cases, over 2,000 sets of medical records, and accounts gathered from families and staff.
It is frustrating that, as Ms Ockenden says herself – 'Many of the themes identified throughout the report are not new to those who oversee maternity care in England.'
Understaffing, toxic culture, bullying and racism
The report found considerable issues with understaffing on maternity wards, but beyond that paints a horrifying picture of 'toxic cultures and poor behaviours' by senior staff. Midwives described behaviours that were unprofessional and 'cruel' to women, with attempts to escalate concerns going unheeded. Staff also described bullying and reported that raising concerns 'sometimes led to criticism, minimisation, or even threat.' The report concludes that there appeared to be an ‘enduring culture of bullying, racism, poor people management and low staff morale across the whole Trust’. How can safe care possibly be consistently provided in these circumstances?
Failures were also noted in recognising and responding to vulnerable patients, including those with language barriers. The report references staff being encouraged by those leading the labour ward to delay admission or keep mothers at home, and staff reported being fearful of pulling the emergency buzzer. These findings particularly resonated with me having acted for children whose births were unnecessarily delayed with terrible consequences.
Further troubling findings were that challenges identified in the review were known 'by service and corporate leaders as far back as 2015' but that ‘a number of known issues, challenges and failings in maternity were at various times sidelined and ignored, deemed too difficult or were of insufficient priority.'
It is highly noteworthy that while more than 830 current and former staff engaged with the review, a number of senior colleagues did not, which has led to a call for a statutory public inquiry into maternity failings - one that could compel evidence.
Brain injury and cerebral palsy
The review identified multiple examples where failures in neonatal care may have contributed to long-term brain injury and adverse neurodevelopmental outcomes. Cases were noted where 'babies experienced severe hypoglycaemia with prolonged low blood glucose levels, seizures, or hypoxic brain injury,' with some of these injuries found to be avoidable. Injuries of this nature are utterly devastating, with potentially vast lifelong consequences.
From my own experience of medical negligence cases, learning from when things go wrong is the key to improving future care. The report details that families were not consistently included in learning processes, with some reporting that their accounts were altered or that things were 'covered up.' This failure to listen to patients, be upfront, and learn from problems is a theme found across multiple reports into maternity care.
Unfortunately, given my experiences in working for children affected by birth injuries and their families, while I am deeply saddened, I am not shocked by this report. My team at Kingsley Napley has been writing about these issues for many years — see our blogs on birth injuries and maternity services here: Birth | Kingsley Napley.
Moving forward
Nationwide concerns around maternity services are being considered by Baroness Amos, appointed last August as chair of the National Maternity and Neonatal Investigation. Her final report is expected imminent and the recommendations she will make are keenly anticipated.
The Ockenden report sets out immediate and essential actions applicable to Nottingham but also to maternity services across England. Key to these is that women must be at the centre of clinical communication and informed decision-making, and must be able to seek additional clinical review through Martha's Rule. My colleague Kirsty Allen having recently written an article querying when Martha's Rule would include maternity services, I am relieved that in response to the report it has been announced that there will be an extension of the Rule to all maternity settings.
Other recommendations that struck me as particularly important include: a mandatory field in triage documentation to capture the woman's own account and concerns; meaningful communication with parents — including use of translation where required — as routine practice; robust processes for information-sharing between organisations to enable accurate risk assessment; and clear maternity-specific Duty of Candour guidance.
I share the report's conclusion in its great sadness for those involved, and in the hope that 'through listening to the experiences of women, families and front-line staff,' trust in maternity and neonatal services can begin to be rebuilt.
My final reflection is that Donna Ockenden makes reference to the statistics around the cost of clinical negligence claims, which have received considerable recent press attention. However, she noted that behind the figures are 'the incalculable effects — financial, physical, emotional and psychological — on the families themselves,' and I would suggest that the findings of her report serve to further underpin this.
Further information about the work of the Kingsley Napley team can be found here:
- Cerebral Palsy causes and claims. Birth injury claims. Legal advice you can trust from experienced Lawyers, Solicitors London
- Jaundice and Kernicterus Claims | Kingsley Napley
- Erb's Palsy Claims | Kingsley Napley
- Group B Strep Claims | Kingsley Napley
Read about birth injury cases we have acted in - Case Studies | Kingsley Napley
Beyond the statistics: a birth injury lawyer's reflections on the Nottingham Ockenden Report
After four years, the much-awaited government-commissioned independent review of maternity services at Nottingham University Hospitals NHS Trust has been completed and published. Led by Donna Ockenden, the review was prompted by significant concerns about the quality and safety of maternity services at the Trust.
Brain injury: the hidden impact of isolation
A brain injury can change a person's life in an instant and the consequences can extend far beyond the physical. One of the most profound, and often overlooked, effects is isolation. The withdrawal from relationships, community - everyday life.
Acclaim for Martha’s Rule - but when will maternity services be included?
I am extremely pleased to see the continuing roll-out in the UK of Martha’s Rule (see our previous articles on this topic here, here and here) and that a recent NHS England report demonstrates that the rule is having a very positive impact. Patient empowerment and clear communication, the embodiment of this rule, are critical components in avoiding medical accidents and poor outcomes. I am particularly keen to see the implementation of this rule being extended to maternity and neonatal settings, an area where, as a specialist birth injury lawyer, I see avoidable harm all too often.
Richard Lodge co-authors new edition of Clinical Negligence handbook
We are delighted to announce that Richard Lodge, Partner in our Medical Negligence and Personal Injury team, has jointly authored Clinical Negligence: A Practitioner’s Handbook - Second Edition with Elizabeth‑Anne Gumbel KC of 1 Crown Office Row Chambers.
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The Medical Defence Union is lobbying Parliament for changes to laws relating to clinical negligence claims. It has written an open letter to the Chancellor of the Exchequer for ‘decisive action to tackle soaring legal costs’. Among its requests, the MDU is repeating its position that section 2(4) of the Law Reform (Personal Injuries) Act 1948 should be repealed. This legislation requires awards of compensation for future care needs, to be based on the cost of future private care and to disregard the availability of treatment within the NHS.
Multiple missed opportunities in paediatric orthopaedic care at Addenbrooke's Hospital
Cambridge University Hospitals NHS Foundation Trust have published a report dealing with concerns around the practices of a trauma and orthopaedic consultant, Ms Kuldeep Stohr, who specialised in treating children at Addenbrooke's Hospital. A clinical review of 800 patients is now underway. Ms Stohr has been suspended.
Unique and United on World Cerebral Palsy Day 2025
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Where Every Minute Counts: Hypoxic Birth Injuries – Causation and Material Contribution
Legal claims for hypoxic brain injuries during birth – caused by a disruption in oxygen supply - remain prevalent. These injuries can have a devastating impact and lead to lifelong conditions including Cerebral Palsy. Indeed, claims relating to brain injuries sustained during birth account for a significant percentage of the total value of clinical negligence damages paid out each year. This is because the average amount of damages for such cases is very high, not infrequently running to tens of millions of pounds, with some impacted children having lifelong needs for care, treatment, equipment and housing. Nonetheless, claims for clinical negligence in this area can be particularly thorny to prove. In this article I consider when the doctrine of ‘material contribution’ – said by the Court of Appeal to have been ‘bedevilled by apparent inconsistency’ – may apply to hypoxic birth injury cases where the window for avoiding injury can be short. Does every minute really count?
14 Maternity Trusts to be Scrutinised as Part of National Investigation
The Government has this week confirmed the names of 14 Hospital Trusts that will be part of a rapid national investigation of maternity and newborn baby care across England that was announced by Wes Streeting back in June. (See my colleague Sharon Burkill’s blog on that announcement here). I am carefully watching the developments with regard to this investigation, knowing full well from my clients and their stories how desperately improvements to our maternity services are needed.
Kingsley Napley’s Medical Negligence Team ‘walks together’ with the Dame Vera Lynn Children’s Charity
We were delighted to take part in a 15km walk on Saturday 6 September for the Dame Vera Lynn Children’s Charity (DVLCC) to raise funds for this excellent cause.
HSSIB contributes to the national investigation into maternity and neonatal services – but will change ever be implemented?
The Health Services Safety Investigations Body (HSSIB) has shared insights into safety concerns raised by women and families and other stakeholders about maternity and neonatal care within NHS England, highlighting once again the need for meaningful change.
NHS Patient Safety Investigations: Have I got a Legal Claim?
Where there has been a concern surrounding medical care at an NHS Hospital, an internal investigation may be carried out and a written report produced to assist with learning from the incident. From a patient perspective, the report can be helpful in understanding more about the event and what, if anything, went wrong.
Problems with glaucoma care at the George Eliot Hospital NHS Trust
We are extremely concerned to read reports that treatment guidelines relating to glaucoma allegedly have not been followed at the George Eliot Hospital NHS Trust in Warwickshire, leading to patients’ sight being harmed. Some patients are said to have suffered permanent visual damage.
NHSR Annual Report: Clinical Negligence under the spotlight
Each year NHS Resolution, the body dealing with legal claims against the NHS, produces a report which provides insights into what is happening with clinical negligence claims. This year the picture is very mixed. It shows that claims for clinical negligence are on the rise although more cases are being settled without the need for Court proceedings. Nonetheless, despite Government efforts, high levels of maternity cases and associated costs persist.
Providing Medical Treatment to a Non-English-Speaking Patient
In this blog, we talk about providing medical treatment to a non-English speaking patient
Outdated, Failing and in Short Supply: NHS Equipment Crisis Putting Patients at Risk
According to a recent article in The Guardian NHS England has confirmed that since 2022, equipment failures within the NHS have been responsible for:
- 87 patient deaths
- 68 patients severely harmed who suffered permanent damage or reduced life expectancy
- 522 patients moderately harmed whose independence was subsequently limited for up to 6 months
James Bell published in the APIL PI Focus Magazine
Kingsley Napley’s head of Medical Negligence and Personal Injury has had an article published in this month’s APIL PI Focus magazine which includes a collection of articles examining the topic of birth injury. James’ piece deals with causation and the doctrine of material contribution in legal claims for hypoxic brain injuries during birth.
When metal hip replacements go wrong
Hip replacement surgery is very common, restoring mobility and quality of life to thousands every year in the UK. It is recognised to be the most cost effective for the NHS in returning patients to productive lives. The components wearing surfaces may be metal, ceramic or plastic, and will often last over 20 to 25 years, or even longer for some people.
Is this the turning point for maternity care?
Concerns over NHS maternity care are very sadly seldom out of the news. As a lawyer who has specialised in birth injury claims over many years, it has been all too clear to me for a long time, that far too many women and babies, fail to receive anywhere close to adequate maternity care leading in some instances to devastating outcomes.
Why Fatigue of NHS Staff Matters and the Risk it Poses to Patient Safety
Fatigue within the NHS presents a significant risk to patient safety, yet in healthcare its consequences remain largely unrecognised despite the increasing demands on NHS workforces.
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