The Largest Maternity Review in NHS History to Be Published

Largest maternity review in NHS history – The National Health Service (NHS) is set to release its most extensive maternity review ever conducted, a report that will shed light on systemic issues within Nottingham University Hospitals NHS Trust. This review, initiated in September 2022, has involved over 2,500 families and more than 800 healthcare professionals, with the goal of uncovering why multiple preventable baby deaths and avoidable harm occurred at the trust’s maternity units. The findings are expected to highlight critical failures in care that have affected patients across two hospitals: Nottingham City Hospital and the Queen’s Medical Centre.

A Legacy of Failures and Financial Penalties

The trust has already faced significant consequences for its shortcomings. In 2021, it received a record £1.6m fine for maternity-related negligence, marking the largest penalty ever imposed on an NHS trust for such issues. This came after the tragic deaths of three infants, which prompted regulatory scrutiny and a deeper examination of its practices. The latest review is a continuation of this effort, aiming to provide a comprehensive analysis of the trust’s performance and its impact on families.

Nottinghamshire Police has been actively involved in the investigation, launching a manslaughter case against the trust in June 2025 as part of its broader criminal inquiry, Operation Perth. This operation has explored whether negligence or misconduct contributed to fatal outcomes. The police investigation runs parallel to the review, which has been led by Donna Ockenden, a senior midwife, and is scheduled for release on Wednesday. The report will serve as a critical reference for understanding the scale of the problems.

From Stillbirths to Systemic Criticism

One of the most poignant cases tied to the trust is that of Harriet Hawkins, whose stillbirth in April 2016 sparked a chain of events. Jack and Sarah Hawkins, who both worked at the trust, were among the first families to demand accountability after their daughter’s body decomposed so severely that it had to be triple-bagged for her funeral. An initial internal review concluded that Harriet’s death was due to an infection, but the family contested this and pushed for an independent investigation.

The external review, published in January 2019, revealed a range of issues, including communication breakdowns, inadequate staffing, and delays in identifying complications. It concluded that Harriet’s death was “almost certainly preventable,” underscoring the trust’s failures in providing safe care. Jack Hawkins, who was a hospital consultant at the time, expressed his frustration in a statement:

“How on earth have we allowed it that there are 1,000 avoidable baby deaths in this country every year and, in a particular place, there are this many schools’ worth of children missing or damaged beyond belief, and dead mums and damaged mums? How have we got here?”

Sarah Hawkins, a senior physiotherapist, added:

“It’s massive, because we worked there as well. We couldn’t go back to our careers, our jobs, everything. Every single aspect of life was changed. I know a lot of Nottingham families just want some form of justice, to clear their children’s name, to know that the harm that was caused wasn’t their fault.”

The family’s legal battle resulted in a £2.8m settlement, believed to be the highest payout for a stillbirth negligence case in NHS history.

Other Tragedies and Ongoing Scrutiny

The review also addresses the case of Wynter Andrews, the daughter of Gary and Sarah Andrews, who died just 23 minutes after birth in 2019. The trust admitted to failures in Wynter’s and Sarah’s care, leading to an £800,000 fine in January 2023. Gary Andrews emphasized the importance of the report, stating:

“The report being published today needs to serve as a wake-up call to the NHS locally and nationally, that what’s gone on before cannot be allowed to continue.”

Meanwhile, the trust has faced additional scrutiny from healthcare regulators. The General Medical Council (GMC) and Nursing and Midwifery Council (NMC) are investigating individual staff members for alleged misconduct. These regulatory actions follow the police’s focus on corporate manslaughter, which has included the arrest of two men in June 2025. They were detained on suspicion of misconduct in public office, linked to “operating practices in the mortuary service” but were later released on bail with strict conditions.

Broader Implications and Calls for Justice

As the review nears publication, the families affected by these tragedies are urging for a statutory public inquiry. This would allow for a more thorough examination of the trust’s practices and ensure accountability across the NHS. The Hawkins and Andrews families, among others, have become vocal advocates for change, sharing their experiences to highlight the human cost of systemic failures.

The review’s release coincides with a period of heightened awareness around maternity care standards. It is hoped that the findings will not only address past mistakes but also drive reforms to prevent similar incidents in the future. The trust’s history of fines and settlements underscores the financial burden of its errors, yet the emotional toll on families remains profound.

The Road Ahead

With the report’s publication imminent, the focus will shift to how the findings are used to shape policy and improve patient safety. The ongoing police investigation and regulatory reviews indicate that the trust’s actions are being scrutinized at multiple levels. For families like the Hawkins and Andrews, the report represents a chance to see their stories acknowledged and to push for lasting change within the NHS.

As the review details its comprehensive analysis, it is expected to provide a roadmap for addressing the root causes of these preventable deaths. The trust’s history of incidents, combined with the ongoing legal and investigative processes, highlights the need for a unified approach to maternity care. The final report may serve as a pivotal moment for the NHS, forcing a reckoning with its past and a commitment to the future.

A Call for Accountability and Reform

Jack and Sarah Hawkins, now parents of a four-year-old son named Bowie, have shared their journey to illustrate the long-term impact of the trust’s failures. Sarah reflected on the emotional weight of their experience, saying:

“I think, personally, it’s got harder because we watch Bowie grow up and realise all the milestones we’re missing with Wynter and that’s heart-breaking.”

Their words resonate with other families who have endured similar losses, emphasizing the need for transparency and justice.

The NHS’s largest maternity review is more than just a report; it is a testament to the collective efforts of those affected and the systemic challenges within healthcare. As the findings are unveiled, they may spark a new era of accountability, prompting the service to prioritize patient safety and address the gaps that have led to tragic outcomes. For now, the anticipation builds as families await the conclusion of this critical examination of their care.