Ockenden report must be the moment maternity care changes, says Leigh Day

The final report, led by senior midwife Donna Ockenden, is the largest maternity review in NHS history. More than 2,500 families and over 800 members of staff contributed to the investigation, which examined cases between April 2012 and May 2025, including stillbirths, neonatal deaths, maternal deaths, severe maternal harm and cases involving babies who suffered significant hypoxic brain injury. 

The review found that more than 500 mothers and babies suffered potentially avoidable harm or died due to “deeply embedded systemic failures”. It concluded that opportunities to recognise deterioration, escalate concerns and intervene appropriately were repeatedly missed over many years, while some incidents were downgraded or inadequately investigated, limiting opportunities for learning and accountability.

The report also identified widespread concerns about failures to listen to women and families, poor telephone assessments, delays in care, inadequate fetal monitoring, failures to escalate concerns to senior clinicians, staffing shortages, bullying and toxic workplace cultures, and a culture in which serious concerns raised by staff and families were too often dismissed rather than acted upon. The review further highlighted inequalities in care, including reports of racism and inadequate support for women whose first language was not English.

The report sets out a list of "immediate and essential actions" to improve maternity care and safety across England:

1. Listening to women and families
2. Workforce planning and safe staffing
3. Training and multi-professional learning
4. Risk assessments throughout pregnancy
5. Incident investigation and family involvement
6. Governance and board accountability
7. Culture, teamwork and psychological safety
8. Mothers and babies who have died and their post-death care

The publication of the report also comes as the government announced that Martha’s Rule will be rolled out across all maternity settings in England. The initiative will give parents and families a formal route to seek an urgent second opinion if they are concerned that a mother or baby’s condition is deteriorating and that those concerns are not being acted upon.

Leigh Day represents families affected by maternity failures across England and Wales and continues to support calls for stronger national oversight and accountability to ensure that lessons identified in reviews are implemented consistently across the NHS.

Medical negligence partner Sanja Strkljevic said:

"The findings of Donna Ockenden’s review are devastating, but for many of the families we represent, very sadly they will not come as a surprise. Here is evidence of the same failings identified in maternity units across the country for years - women and families not being listened to, concerns being dismissed, opportunities to prevent harm being missed, and organisations failing to learn from mistakes.

"The courage and persistence of the Nottingham families who fought for answers over many years has been extraordinary. Without them, these systemic issues may have never come to light. The stark reality is that when families raise concerns, they must be heard rather than ignored.

"The most troubling aspect of this report is not simply the scale of the harm it describes, but the fact that so many of its findings echo those of previous maternity reviews and inquiries. The families we represent have come to us with strikingly similar accounts from maternity services across the country. We cannot continue to see the same recommendations made, the same promises given and the same failures repeated.

"The report is an inarguable case for reform and national accountability. We support calls for the appointment of a national maternity commissioner with the independence, authority and oversight needed to ensure these failures are acted upon, and improvements are delivered consistently across the NHS, rather than relying on individual trusts to police themselves.

"We agree that the report demonstrates the consequences of sustained failures in leadership, governance and accountability. When concerns are dismissed, incidents are minimised and women are not listened to, harm becomes more likely and opportunities to prevent future tragedies are lost. The families at the centre of this review have paid an unimaginable price for those failures.

"As we all now look to Baroness Valerie Amos’s national maternity review next week, there must be a determination not simply to catalogue failings, but to change. Families expect a maternity system that is, first and foremost, safe. They expect a system that learns from mistakes, listens to women and puts safety ahead of institutional reputation. The legacy of this report must be action."

Leigh Day’s medical negligence triage team is headed by registered midwife Helen Stanley. She said:  

"One of the most concerning findings in the report is the evidence that some women were discouraged from attending hospital or were not given timely access to in-person assessment when they raised concerns.

"Women who contact maternity services are often doing so at a moment of significant anxiety and vulnerability. They should be met with compassion, respect and appropriate clinical support. Personalised care and access to one-to-one midwifery support are not optional extras, they are fundamental to safe maternity care.

"No woman should feel that she has to fight to be heard or that access to care is being gatekept. Listening to women, responding appropriately to concerns and ensuring timely assessment are some of the most effective steps maternity services can take to improve safety and rebuild trust."