Nottingham Maternity: Donna Ockenden to Chair Independent Inquiry

Stephanie Prior
doctor women at office

Table of Contents

An interim report on the state of maternity services at Nottingham University Hospitals NHS Trust has just been released. However, after around 100 women wrote to Health Secretary Sajid Javid, criticising the report, Donna Ockenden was appointed to head up a separate, independent investigation into the Trust.

A senior midwife with more than 30 years of experience, Donna Ockenden was Chair of the England Royal College of Midwives between 2006 and 2014. She more recently and more famously, led the Shrewsbury and Telford NHS Trust investigation into deaths of over 200 babies who died due to failings in maternity care there. Ockenden will now focus her experience on the more than 500 cases of women and babies who suffered harm while ostensibly under the care of the Nottingham University Hospitals NHS Trust.

In a letter from the Chief Operating Officer of NHS England and NHS Improvement, affected families were told, ‘I can confirm that Donna Ockenden has agreed to chair the new Review and we will work with her to develop a new Terms of Reference that reflects the need to drive urgent improvements to local maternity care and the need to deliver actionable recommendations that can be implemented as quickly as possible’.

Interim report: review of incidents at Nottingham University Hospitals NHS Trust

So, what were the findings of the interim report and why was it rejected, to be replaced by a new Ockenden review? Released in April 2022 the interim report rated the Nottingham University Hospitals maternity service as ‘inadequate’, blighted with cultural and staffing issues. Failings included poor leadership and a culture resistant to learning lessons. Other concerns included lack of training, insufficient risk assessment of patients, inadequate medicine management, a culture of bullying behaviour and an overall lack of respect.

Despite being critical of Nottingham’s maternity services, the review was rejected by campaigners due to its lack of independence and apparent inadequate investigative remit. And although the Chief Executive of the Trust apologised for the problems identified by the report and offered reassurances that ‘significant changes’ were being made to address the issues, including ‘hiring and training more midwives and introducing digital maternity records’, local women remain to be convinced. Indeed, it has been reported that families who have conceived again moved home from out of the area, so that their pregnancies would not fall under the remit of the Nottingham Trust.

In response to the Ockenden appointment, the NHS England Chief Operating Officer said, ‘after careful consideration and in light of concerns […] that the current (interim) review is not fit for purpose, we have taken the decision to ask the current review team to conclude all of their work by Friday 10 June 2022. We will be asking the new national review team to begin afresh drawing a line under the work undertaken to date by the current local review team’.

National attention and calls for a public inquiry

The problems in the Nottingham maternity services first came to national attention in 2021 following a Channel 4 News and Independent report that between 2012 and 2020, 46 babies suffered brain damage and 19 were stillborn in the Trust. In subsequent investigations, it was found that relevant medical notes were missing or never made, and others were completely inaccurate. Furthermore, several deaths were never investigated, and outcomes of those that were actually completed, were minimised by hospital management. To date more than £91million in damages has been paid out to families.

Many of the affected families have spoken out about their experiences and have called for this external review so that the truth is uncovered. Ms Ockenden said that ‘clearly something is very, very wrong at the Trust’ and her priority is to listen to the families.

The issues in the maternity services have been known for some time. In 2018, doctors and midwives sent a letter to the Trust board stating that inadequate staffing levels were impacting patient safety. As recently as March 2022, it was determined that the maternity service did not have enough staff to care for women safely and since then warnings have been issued over safe care and treatment, especially pertaining to clinical observations and triaging of new patients. The Care Quality Commission said, ‘It’s disappointing that despite several inspections […] serious problems remain’.

Families formally respond to Ockenden’s appointment

The families affected by the failings of the Trust released a statement, ‘We cannot describe the immense sense of relief that we feel at the news that Donna Ockenden has been appointed. We are confident that she will conduct a robust review to ensure the scale of failings […] are recognised and essential improvements are made. Donna Ockenden’s appointment is a significant step towards restoring confidence in Nottingham maternity services’.

A change in the law?

Under the Coroner and Justice Act 2009, in England and Wales, a stillborn child is not classified as a ‘deceased person’, so an inquest into their death does not need to be held. Campaigners believe that if a coroner’s inquest had been held into other stillborn children at the Trust, the institutional problems would have been identified earlier and changes initiated. Perhaps it is indeed time to consider a change in the law.

If you’d like to speak to the medical negligence department regarding similar matters, contact Stephanie Prior or complete an online enquiry form.

Share this article


Contact us today

For a free initial conversation call 020 7485 8811

Email us Send us an email and we’ll get back to you

    • "Stephanie Prior is very empathetic and practical, she gets to the heart of a case quickly."

      Legal 500 2023

    • "Stephanie Prior is highly respected in the marketplace, with a great wealth of experience, superb judgment and medical knowledge that is second to none."

      Legal 500 2023

    • "Stephanie has always shown great judgment and common sense whilst building valuable relationships with her opponents."

      Legal 500 2023

    • "Stephanie Prior is a standout solicitor."

      Legal 500 2023

    • "Stephanie Prior is an experienced lawyer with immense knowledge of her specialism, which allows her to run her cases with strategic precision."

      Legal 500 2023

    • "Stephanie knows her way effortlessly around any clinical negligence issue and has a great strategic mind."

      Legal 500 2023

    • "I know [we have] expressed our appreciation, but I also wanted to thank you for all your hard work, time and patience in pursuing mum’s claim through to a successful outcome - your kind and professional approach was genuinely appreciated."

      Client review

    • “May I take this opportunity to thank you for your patience and true compassion in yet another very tough year of representation on the behalf of my wife. I certainly must say you did it all with amazing stamina and positivity which regenerated my self-esteem…. You honestly eased the pain and I can see a healing process ahead.”


    • Stephanie has developed a particularly strong reputation for her handling of birth injury claims, as well as cases concerning surgical negligence and delays in surgery.

      Chambers UK

    • "An excellent firm which achieves fantastic outcomes for clients."

      Legal 500 2021

    • "Stephanie Prior takes on complex cases and gets excellent results. She has a background in medicine which serves her clients well and is a realistic but tough litigator."

      Legal 500 2021

    • "Stephanie Prior is hugely dedicated, adored by her clients, tenacious, efficient and extremely knowledgeable."

      Legal 500 2021

    • "Stephanie Prior is very good with troubled clients and is easily able to make them feel at ease."

      Legal 500 2021

    • "Stephanie shows sensitivity and deals with things in an understanding way."

      Chambers UK 2021

    • Osbornes provides a very intimate and personal client service which is increasingly rare in this sector.

      Legal 500 2020 - Clinical Negligence

    • The lawyers in the team are highly experienced and will drive cases very hard on behalf of their clients.

      Legal 500 2020 - Clinical Negligence

    • "Stephanie Prior has a realistic attitude to the complexities of the cases. She wins the trust of her clients and goes the extra mile to ensure they get the best outcomes."

      Legal 500 2020 - Stephanie Prior

    • Stephanie’s background in medicine gives her an ability to read between the lines where medical records and expert evidence are concerned and is a great asset.

      Legal 500 20202 - Stephanie Prior

    • "Her knowledge base is second to none and her understanding of the litigation process stands out, as does her ability to work collaboratively."

      Chambers UK

    • "Stephanie Prior... manages a varied caseload, including obstetric claims, child and adult brain injury cases and fatal and non-fatal spinal cord injury cases."

      Chambers UK

    • "Stephanie is experienced, knowledgeable of all aspects of clinical negligence work, and strategic in running cases."

      Chambers UK

    • "Key team members include the approachable, compassionate and efficient Stephanie Prior."

      The Legal 500

    • "The team were extremely professional in putting my needs first. There was a joined-up approach to catering for the client, and all lawyers involved were briefed and constructive."

      Chambers UK

    • Stephanie Prior is always very professional and kind. Highly recommended.

      Medical Negligence Client

    • Quite simply excellent, with a highly competent and well-rounded team. They understand complex medical litigation and have been our lifesavers, and we will always owe them our immense gratitude.

      Medical Negligence Client

    • Stephanie Prior is ‘very warm’ and ‘caring’, and an ‘exceptional professional’.

      Legal 500

    • Stephanie Prior continues to receive widespread praise from clients, who state that she explains the legal aspects of the case very clearly, and she is also a caring person who handles cases on a personal level.

      Chambers UK

    Related InsightsVIEW ALL

    1. new born baby

      Early Notification Scheme – is it helping or failing...

      What is the Early Notification Scheme? The NHS Early Notification Scheme (“ENS”) has reached its sixth anniversary. Established in April 2017,...

      Read more
    2. 5.6.2023

      Are pharmacy closures putting patients at risk?

      It has been reported in the press that chemist closures will have an impact on patients living in deprived or...

      Read more
    3. Confidential file

      Osbornes Instructed After Local Authority Data Breach

      Osbornes Law have recently negotiated a settlement on behalf of two clients who had their personal information inadvertently released to...

      Read more
    4. pregnant lady

      Private Pregnancy Scans and Substandard Care

      In the news, it has been reported that private clinics that offer pregnancy scans to women are not meeting the...

      Read more
    5. baby hand in mothers hand

      5-figure settlement for infusion leak to mother

      Elline Demetriou has reached another successful outcome for a Claimant, who pursued a post C-section birth injury to mother claim...

      Read more
    6. Cannula in right arm of indian man

      The risk of extravasation injuries during iron infusion...

      Many patients with low iron, particularly during pregnancy or postnatally, may be advised they need an iron infusion such as...

      Read more
    7. water

      Perineal Tear case settles for 6-figure sum

      Stephanie Prior recently settled a birth injury claim relating to a woman who delivered her baby after a traumatic labour....

      Read more
    8. dentist

      Court avoided after settlement agreed in dental negligence...

      The Medical Negligence team have recently negotiated the settlement of a complex dental negligence case. Our client experienced a number...

      Read more
    9. Doctor With Stethoscope And Files

      Delayed cancer diagnosis results in five figure settlement

      The medical negligence team at Osbornes Law has recently settled a case involving a patient who passed away following a...

      Read more
    10. hands of surgeon

      Successful settlement for negligent care during kidney transplant...

      Claimant v Royal Free London NHS Trust Osbornes have reached a settlement agreement on behalf of a Claimant who brought...

      Read more
    11. Modern dental office interior

      Successful claim against dental practice after negligent treatment

      Osbornes Law have reached another successful outcome for a client, who pursued a claim against dental practitioners due to medical...

      Read more
    12. Ambulance outside a hospital Accident and Emergency department.

      Transfer time from ambulance to A&E causing...

      The Healthcare Safety Investigation Branch (HSIB) have identified that patients may come into risk of harm whilst waiting in ambulances...

      Read more
    13. The doctor looks at the x-ray

      Breast cancer screening mammograms and negligence

      Breast cancer screening has improved significantly in the UK due to research bettering the understanding of this terrible disease, which...

      Read more
    14. Doctor Or GP In Office Meeting Teenage Female Patient

      Women more likely to have symptoms ignored by...

      An increasing number of women in the UK feel brushed off by GPs when presenting with real symptoms, with many...

      Read more
    15. Hospital sign MATERNITY

      Are maternity services safe? – Part 2

      In April last year I wrote a piece about government setting up a taskforce to look into why there are...

      Read more
    16. Pregnant woman performing cardiotocography CTG

      Poor interpretation of CTG can result in stillbirth...

      Poor interpretation of a Cardiotocograph, more commonly known as a CTG, is a leading cause of stillbirth and brain injuries...

      Read more
    17. asian old man devastated by bad news

      New interactive rating tool reveals NHS wait times...

      Amidst record-breaking heatwaves and a lengthy patient waiting list due to COVID backlogs, it is not surprising that this summer...

      Read more
    18. Medical doctor in empty hospital corridor

      Successful settlement for birth injury that led to...

      Stephanie Prior’s case relating to the death of Gabriela Pintilie has settled and has been approved by the High...

      Read more
    19. Insulin injection needle or pen for use by diabetics

      Insulin overdose in hospitals due to limited staff...

      A century ago, insulin was first used to treat a 14-year-old boy dying of type 1 diabetes A hundred years later,...

      Read more
    20. Doctor

      GP Negligence claim leading to fatality successfully settled

      Osbornes acted for a Claimant who brought proceedings on behalf of the estate of her late son, X, relating to...

      Read more
    21. NHS Building

      NHS aims to reduce waiting times with Elective...

      The NHS recently recorded their waiting list to be at 6.5 million, a record high. Much of this backlog is due...

      Read more
    22. Neglijenta medicala spital din UK

      Justice for client who suffered serious birth injuries

      The Clinical Negligence team at Osbornes Law have recently negotiated the settlement of a case in which our client sustained...

      Read more
    23. 28.4.2022

      Calls for Public Inquiry into Vaginal Mesh Surgery

      A leading professor from the University of Oxford has called for a public inquiry into the use of vaginal mesh...

      Read more
    24. Female surgeon wearing surgical mask

      Severe abdominal pain prolonged due to failed surgery

      Jodi Newton was instructed in a claim against London North West University Healthcare NHS Trust where our client suffered serious...

      Read more