61 serious maternity incidents at Nottingham hospitals yet to be passed to Ockenden review

Nottingham University Hospitals failed to tell independent review of 61 incidents

Managers at Nottingham Hospitals Trust (NUH) continue to investigate 61 serious incidents involving maternity cases where patients have been injured.

All 61 cases were not passed on to the independent review team looking into the city's maternity unit 'failings'.

Twelve of these include maternal deaths, neonatal deaths, stillbirths, or severe brain injury in babies and date back to 2019.

Serious incidents are considered unexpected or unintended events which could cause harm to NHS patients.

Despite previously having a 60-day target to complete the investigations, papers from the NUH board say 54 of the 61 serious incidents have exceeded the usual deadlines.

The oldest of these newly recovered incidents happened in 2019 before the coronavirus pandemic.

Eight of the 61 incidents occurred when a maternity unit was closed unexpectedly and mothers had to be transferred.

All incidents add to more than 200 other incidents the review team is looking into after Nottingham University Hospitals Trust was declared as 'inadequate' by healthcare watchdogs.

Senior midwife Donna Ockenden is leading the independent review into maternity services at the trust.

Donna Ockenden chairs the independent review into Nottingham University Hospitals Credit: PA

In total, more than 700 families and 160 members of staff contacted the independent review team since it started work last month to share their experiences.

The government appointed the Ockenden review team, following a campaign by families whose babies died or were injured under the care of the trust.

Sarah and Jack Hawkins, from Nottingham, were one of the families campaigning and recently received a payout from the NHS when their daughter Harriet was stillborn in April 2016.


  • Sarah and Jack Hawkins say these newly uncovered incidents have left them shocked and horrified.

Sarah said: "We're not talking about, 'Oh the buzzer didn't work on the ward', we're talking about families having dead babies that should be alive.

"We're talking about dead mothers, we're talking about seriously damaged babies that will have disabilities for the rest of their lives.

"This is massive. How can this not be investigated."

More than one NUH board member has described the incident investigation backlog as “unacceptable”.

During September’s board meeting, Director of Midwifery Sharon Wallis said: "We have a significant number of Serious Incidents.

"We have a cluster being reviewed. We have support from the regional team to try to get through the backlog."We need to understand where things have gone wrong and learn lessons for families."I’ve personally spoken to one of the women [involved] and apologised profusely because it isn’t good enough."The trust runs maternity services at the Queen’s Medical Centre and Nottingham City Hospital and says it hopes to complete investigations into the remaining serious incidents by December 2023.

During the September board meeting, non-executive director at NUH Professor John Atherton admitted the number of SI investigations was unacceptable.He said: “We apologise sincerely and we are doing everything we can to try to make things better.

"I also thank the staff in the trust who are working as hard as they can to put things right.“I believe all the incidents currently outstanding should be dealt with by Christmas.

"It is a priority that we get that backlog down.”Dr Keith Girling, medical director at Nottingham University Hospitals Trust, added: “We are sorry to those people where there has been any form of incident during their care.“We acknowledge we have a backlog of cases and we are committed to ensuring that there is regular contact with families to keep them updated on the progress of the investigation.”

More than 700 families and more than 160 members of staff have contacted the independent review team, to share their experiences, since it started work last month.

Prof Atherton said: “We apologise sincerely and we are doing everything we can to try to make things better.

"I also thank the staff in the trust who are working as hard as they can to put things right.

"I believe all the incidents currently outstanding should be dealt with by Christmas. It is a priority that we get that backlog down.”

The NUH board will be updated on Serious Incident investigations at its next meeting, on November 24.