Baby deaths and toxic culture - the Nottingham maternity report at a glance

Image source, PA Media Image caption, Donna Ockenden led a press conference on Wednesday to mark the review's publication By Gavin Bevis East Midlands Published 37 minutes ago Hundreds of mothers and babies suffered potentially avoidable harm or died due to "deeply embedded systemic failures" at maternity units in Nottingham, a review led by senior midwife Donna Ockenden has concluded . The inquiry - the largest of its kind in NHS history - found leaders at Nottingham University Hospitals (NUH) NHS Trust knew there were serious issues in its maternity department going back to "at least 2010", but failed to take action to prevent more harm and deaths. Ockenden said she hoped her conclusions would "drive real and lasting change to maternity services in England". Here are some of the main findings at a glance. Hundreds of affected families About 2,500 families and more than 800 members of staff contributed to the inquiry, which started in 2022. Overall, experts concluded there were "potentially avoidable" outcomes for mothers and babies in 444 maternity cases leading up to May 2025 alongside 76 neonatal cases. All these cases were graded as two or three for harm - with grade two representing "significant concerns" and grade three "major concerns" over care. Different care may have altered the outcome for 260 babies, who died or were harmed, the review team told the BBC. Of that number, 155 babies died while 105 suffered serious injury due to substandard care, with some left with permanent brain damage. Multiple factors to blame The review concluded the harm was rarely the result of a single issue or specific failing. Experts found adverse outcomes were linked to multiple factors, including failures in the monitoring of babies, poor interpretation of heart monitoring, a failure to recognise babies were in distress during labour and a failure to escalate some cases to senior doctors. Ockenden added many of the systems of oversight established for maternity care were "no longer fit for purpose". And there was also a major criticism of the trust's workplace culture, which was described as "bullying and toxic" over several years. Women in the middle of labour were told to "pull themselves together" - while another submission from a mother recalled being told to "wait their turn" as there were "other women they had to sort". Image caption, The review examined failings at maternity units run by Nottingham University Hospitals NHS Trust, which runs the Queen's Medical Centre (pictured) Many of the problems detailed in the report have been known about at the trust since "at least 2010", Ockenden said. These include insufficient staffing, and the inability of staff to carry out basic and often mandatory training. Actions set down in the review "when implemented will drive improvement both within perinatal services at Nottingham University Hospitals NHS Trust and across England", she said. Women and families were not listened to Concerns were often dismissed o