Speaking at the press conference on her findings, Donna Ockenden began by praising the Nottingham families who campaigned for years for justice.

She said:

More than 2,500 families came forward to share with my team what happened to them.

Let that number sit with you for a moment – 2,500 families.

Their experiences occurred over more than a decade. And yet the themes that run through those experiences a failure to listen, a failure to investigate, a failure to learn are hauntingly consistent. From 2012 to 2025, year after year, baby after baby, mother after mother, family after family.

This review owes its very existence to a group of families who refused to be silenced. They came together in harm and in grief, united in their determination that what had happened to them should not happen to anyone else.

The press conference on the Ockenden inquiry has begun, you can watch live here:

Paula Sussex, the parliamentary and health service ombudsman, said the report “adds to an overwhelming body of evidence that maternity services are failing women and families in ways that are repeated and preventable”.

In remarks reported by the Press Association earlier this morning, she said:

For years, reviews have highlighted the same issues – failures in communication, not listening, delays in diagnosis, and poor postnatal care. Yet too often these warnings and any lessons have not translated into lasting improvement, resulting in repeated harm.

While many NHS staff work tirelessly to provide excellent care, every woman and baby deserves safe, compassionate care, every time. It is vital now that we focus on fixing the service. NHS leaders must ensure these findings lead to real, sustained action across all Trusts.

Listening to women and families is one of the most effective ways to prevent harm and improve care. We owe it to those affected not just to recognise these failures, but to ensure they lead to meaningful and lasting change.”

A photo from the newswire this morning of families arriving at the Crowne Plaza hotel in Nottingham for the Ockenden report press conference.

‘Truly horrific’: the stories of five people affected by the NHS maternity scandal

In this report by the Guardian’s social affairs correspondent, Jessica Murray, five families recount the devastating consequences of failures in maternity care at Nottingham university hospitals NHS trust.

Among them is Sarah Andrews, whose daughter, Wynter, died in 2019 at the Queen’s Medical Centre from hypoxic ischaemic encephalopathy – a loss of oxygen flow to the brain – which could have been prevented had staff delivered her earlier. Sharing her story, she said:

I went into labour and I was having contractions, and for six days, I was basically told to stay at home. I didn’t feel like I had any other choice. And then in hospital, the care was just beset by failures.

I actually said to my husband I felt like I’d be better off dead than in the situation I was in … It was truly horrific. When they eventually called the emergency C-section and opened me up, the smell of infection filled the room and that’s when they realised that Wynter was stuck in my pelvis. All the warning signs of infection were there.

Me and Gary had to watch for 23 minutes while they failed to resuscitate her. We had staff come visit us in the bereavement suite and they said it was one of those things, that sometimes babies die. One said to us: ‘If we listen to every mother’s concerns, we’d be overrun.’ They’re telling us that they can’t see anything that’s gone wrong. And a year later, at the inquest, the coroner rules that it’s a clear and obvious case of neglect.”

Read more:

Speaking ahead of the publication of the report, Labour MP Michelle Welsh said it was “pure luck” that her own baby had survived birth.

“When it comes to luck, as to whether your baby survives or not, then that is a true indication of a system that is truly, truly failing,” the MP for Sherwood Forest and the government’s first maternity adviser told BBC Radio 4’s Today programme.

When asked whether there was a will within government to change things, she said:

I feel that there is a momentum. I do feel that there is a will.

I mean, I absolutely make sure that I am listened to. I haven’t got in within those doors to sit there quiet and just nod my head. I’m absolutely out there, at the forefront, being very, very loud and clear about the fact that we do need the funding.

But funding alone is not going to solve this crisis. There needs to be huge systematic change. The government has to be bold in the policies that it makes, because tinkering around the edges will not solve this crisis.

And some of these organisations involved are going to have to face these truths, and we are going to have to deal with this head on.”