“You can kill children in this country,” said doctor and grieving father Jack Hawkins in The Times last year. “As long as you do it in an NHS institution, you can go back to work the next day.”
His words are felt all the more keenly now, after an official review has found that hundreds of mothers and babies died or suffered potentially avoidable harm because of “long-standing and deeply embedded systemic failures” at Nottingham University Hospitals NHS Trust. On publication of the Ockenden Report yesterday, Hawkins, whose daughter Harriet died just before birth at Nottingham City Hospital in 2016, said its findings “must be treated with the utmost seriousness”.
What does the Ockenden Report say?
As she conducted her review of the NHS trust’s maternity and neonatal services, senior midwife Donna Ockenden heard from 2,500 families and more than 800 current and former members of staff. “She found that more than 500 babies and mothers might have avoided death or serious injury if their care had not been so abysmally inadequate”, said Poppy Koronka, health correspondent at The Times.
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Ockenden uncovered a “toxic” and “bullying” environment, in which women were subjected to cruelty and brutality, while misgivings about their baby’s safety were ignored. Maternity wards were dominated by a “small minority of powerful leaders who had been allowed on ‘infect‘ the unit” and bully patients and staff. She described labouring mothers-to-be being “coerced” into inductions or interventions or told to stay at home “potentially longer than it was safe to do so”.
Nearly 30 pages of the 400-page report describe Harriet Hawkins’ case because, Ockenden said, her parents’ experience bore so many “hallmarks” of the way other families were consistently “cruelly” treated. An external review in 2018, commissioned after Jack and Sarah Hawkins challenged the hospital’s internal review, found that doctors and midwives had missed 13 opportunities to save Harriet’s life.
Ockenden also found evidence of “recurring examples of failure to protect the dignity” of women and children who had died. Bodies, including that of Harriet Hawkins, were allowed to decompose badly or were “disposed of as clinical waste”. One mother was told that her premature baby, who had died in 2020, was a boy but, five months later, received post-mortem results showing her child was actually a girl. The mother had “already buried the baby as a boy in a blue coffin”, said the report, and “given the baby a boy’s name, which she had tattooed on her body”.
How could this happen?
There was rarely a single issue or a particular failing, concluded the report. Instead there were multiple factors, including failure to monitor unwell babies, incorrect analyses of foetal heart monitoring, poor training, a lack of oversight, poor escalation procedures and a failure to recognise when a baby was in distress during labour.
Pregnant and labouring women repeatedly described feeling unheard, inadequately informed and unsupported, particularly when they were reporting reduced foetal movements or other medical complications. The Trust’s board and leaders were aware of failing maternity services for more than a decade but “sidelined or ignored” them, regarding the issues as “too difficult” or “of insufficient priority” to address.
The Trust’s chair and CEO have now issued an open letter, addressed to “the people and communities of Nottinghamshire”, in which they apologise “unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services”.
What can be done?
Ockenden has called for a series of “immediate and essential” measures to “directly address the failings” her team has identified, including urgent improvements to risk management and monitoring, plus strengthening of escalation protocols, communication and safe transfer of care.
She also recommended strengthening neonatal care with better training on spotting the signs of serious illness, and improving post-death care and bereavement processes.
Health Secretary James Murray has apologised on behalf of the NHS and said “no options are off the table” in terms of next steps. He did indicate, however, that the government might wait until the end of the year to develop any action plan. Ockenden has urged ministers to act sooner, saying: “How much more harm may happen in this country? We don’t have the luxury of six months.”
