Reflections On The Ockenden Report: Why Nottingham’s Maternity Services Must Now Change

Following the publication of Donna Ockenden’s report into maternity services at Nottingham University Hospitals NHS Trust, Julie Hardy reflects on three decades of supporting families affected by avoidable harm, and on the urgent need for lasting change.

As I read the findings of Donna Ockenden’s review into maternity services in Nottingham, I found myself reflecting on the last 30 years of working as a clinical negligence solicitor in this city. I have spent my whole working life in Nottingham and have represented hundreds of patients and families whose lives have been devastated by unexpected injuries suffered while receiving medical care.

Much of my professional life has involved maternity claims. Many of my current and former clients have been involved in the inquiry, including families whose babies suffered hypoxic brain injury leading to serious and lifelong disabilities.

Every family that comes to me after their child has suffered an injury says the same thing: we don’t want another family to experience this. A clinical negligence claim cannot guarantee that, but I have always told clients that sharing their experience can help raise awareness of the failings that led to their child’s injury, encourage learning, and, ultimately, make hospitals safer.

I still believe that. But reading the report was a deeply sad and sobering experience. It is heartbreaking for families to discover that lessons were not learned from their experiences, or from Prevention of Future Deaths reports issued by coroners. Mothers and babies should always be cared for in a safe, compassionate, and properly supported environment.

My own sons were born at Nottingham City Hospital. Neither delivery was straightforward, but throughout my admissions, I felt safe and cared for. I received excellent care. Looking back, I recognise how fortunate I was, but excellent maternity care should never feel like a matter of luck. It should be the standard every woman and baby can expect.

In my experience, the cause of almost every maternity claim I have dealt with has involved either inadequate staffing, or insufficient training and supervision. Donna Ockenden’s recommendations around safe staffing and multi-professional learning are therefore unsurprising. What matters now is that those recommendations are implemented, resourced, and sustained.

Comment

Nottingham has been under the spotlight throughout this review and will remain so as families, clinicians, the Trust, and the wider healthcare system digest the report’s conclusions. It has been a difficult and painful process for everyone involved, but it also presents a crucial opportunity: to make maternity services in Nottingham safer than they have ever been, and to ensure the Trust becomes a place where clinicians are supported and proud to work.

The Government must now build on the bravery of the families, and staff who came forward and the meticulous work of Donna Ockenden and her team. Those families and staff spoke out because they wanted others to be protected. I want to be able to reassure my clients that another family will not experience this.