Nottingham baby deaths: Opportunities to intervene were missed
The Nottingham maternity review has been published this morning.
Last updated 24th Jun 2026
Maternity failings at Nottingham University Hospitals NHS Trust (NUH) go back years, with Donna Ockenden’s review pointing to missed opportunities to intervene and improve care.
The review found there were warning signs at NUH from as early as 2007 including through serious incidents, staff feedback and regulatory inspection.
In total, six external reviews were commissioned into maternity and neonatal care at NUH between 2015 and 2022 and “all were extremely critical of the culture, departmental and consultant behaviour and overall governance of the service”, the report said.
During the period 2015 to 2016, “early warning signals were accompanied by clear opportunities for intervention”, with one external review showing there were issues in leadership and culture, and concerns had been formally raised within the trust.
In 2017, internal reports identified “major weaknesses” in maternity governance and there were “escalating concerns” from the Clinical Commissioning Group (CCG) and NHS England, leading to further scrutiny.
“Although some improvements were reported, there is limited evidence that these resulted in sustained or embedded change,” the report said.
“Several babies died or suffered harm during this period, with incidents often revealing recurring themes: delayed escalation, poor monitoring, and insufficient staffing.”
In 2018, 50 maternity staff submitted a formal letter to the board chair raising concerns about staffing levels and patient safety. And in 2019 the trust was at risk of being placed in special measures.
However, this was the year that more babies died and suffered harm, including babies Kouper Needham and Wynter Andrews.
“Many of the issues described in this report have been known about at NUH since at least 2010,” the study said, such as insufficient staffing, a “persistent failure” to listen to mothers and fathers, and a “corresponding failure to investigate, and therefore learn from, mistakes”.
The report said that by 2020 and 2021, the issues at the trust “had reached a point of systemic failure”.
It added: “Regulatory bodies, including the Care Quality Commission (CQC), and national investigation organisations such as the Healthcare Safety Investigation Branch, national intervention, identified serious and persistent concerns.”
The trust was also put into a national maternity improvement programme, reflecting the severity of the issues.