NCT responds to Donna Ockenden’s review of maternity services at Nottingham University Hospitals NHS Trust

Our thoughts are with the women and parents at the heart of this investigation.

The findings of the report are truly devastating. Women, parents and families experienced unimaginable loss and harm, only to have their concerns dismissed and to spend years campaigning for answers about what happened to them and their babies.

We owe a huge debt to the women and parents whose courage and determination have brought these failings to light. Their voices have exposed both serious failures in care and a culture that too often failed to listen, failed to learn and failed to treat parents with the compassion and humanity they deserved.

The report reveals systemic racism and ethnicity-based discrimination in maternity care. The harrowing lack of dignity in bereavement care for so many families, further compounded their loss. The report exposes that toxic, bullying cultures, which discouraged speaking out or raising concerns led to an environment too often lacking in respect and humanity.

Critically the system was not set up to learn. Repeated opportunities to identify problems, learn lessons and prevent further harm were missed, allowing unacceptable failures, racism and discrimination to continue over many years.

At a time when women and parents are at their most vulnerable, they should be able to trust that they will be listened to, treated with dignity and compassion, and receive safe, high-quality care. This report raises profound questions about the care women, parents and babies received, and what happened when families tried to raise concerns about it.

At NCT, we hear from women and parents every day who describe feeling unheard, dismissed or unsupported during pregnancy, birth and the postnatal period. The experiences described in this report are deeply distressing and underline a longstanding issue of women and parents not being listened to, something families have raised for many years. Our research, 'From expectation to reality', found that six in ten parents are worried about the safety of maternity care. While Donna Ockenden’s review focuses on one Trust, it highlights issues that women, parents, campaigners and charities have been raising for a long time, including racist treatment and discrimination in maternity services.

The report also highlights the pressures facing maternity services. Staff must have the time, training and support they need to build trusting relationships with women and families, provide continuity of care, and deliver safe care. Workforce shortages and sustained pressure cannot be ignored if we are serious about improving outcomes and experiences for women, parents and babies.

This report makes clear that improving maternity care is not only about more funding or more staffing, important though they are. It is also about culture, leadership, accountability and how women and parents are treated. Their concerns must be taken seriously, their voices heard and acted on, and they must be fully involved in decisions about their care. When things go wrong, families must be told the truth and properly involved in understanding what happened.

We welcome both the extension of Martha’s Rule and stronger powers to compel NHS staff to give evidence to future maternity reviews. The recommendations in this report must now be acted on and lead to real change.

Women and parents should never have to fight to be heard when they are worried about their own or their baby's safety. It is now up to leaders across government and the NHS to show the conviction and compassionate leadership needed to drive lasting change, backed by sustained long-term investment. Trust will only be rebuilt if there is accountability at every level. The time for action is now.