What struck me most about the 400+ page Ockenden Report, alongside the harrowing cases it details, is that these were not one-off incidents or isolated mistakes, but systemic failings in leadership, culture, and the way concerns were responded to.
Spanning more than a decade, many families will feel that there is little in this report that they did not already know through their own experiences. In that sense, it is less about new revelations and more about long-overdue acknowledgement of what families have been saying for years.
This report is the result of years of determination by families who refused to be ignored and who pushed for answers when they should never have had to.
The key question now is what happens next? Will this finally be the turning point that leads to safer maternity care, or will families once again hear that “lessons have been learned” without seeing real change?
Having worked on many maternity clinical negligence cases, I feel families deserve more than recognition, they deserve action, accountability, and lasting improvement.
Accountability and leadership
A clear starting point must be honest reflection and accountability from the top down, particularly where concerns were known about but not acted upon.
The report highlights the need to address not only systems, but behaviours and culture — including the failure to listen to women and families when they raised concerns. Real change will only happen if there is a shift in culture, where:
- Families are heard, believed and respected
- Staff feel able to speak up without fear
- Lessons are acted upon, not repeated
Impactful changes
A key part of the report has been the announcements for how not only the NUH Trust will be moving forward, but also how the NHS and government have responded:
- A new learning and improvement board will be created at NUH. This is a positive step, but it will need to be transparent, properly resourced, and genuinely effective in driving change.
- The extension of Martha’s Rule into maternity services is particularly important, giving families a stronger voice and a clear route to escalate concerns when they feel something is wrong.
- Proposals to ensure staff are required to engage with investigations and reviews reflect the importance of openness and accountability, although how this will work in practice remains to be seen.
- There is also a growing sense that stronger national oversight, and potentially further inquiry, may be needed to ensure that the issues identified in Nottingham are not repeated elsewhere.
Families are at the heart of this
At the centre of this report are families who have experienced unimaginable loss, trauma, and life-changing harm. Many have shown extraordinary courage, speaking out and continuing to push for answers despite the emotional toll and, in some cases, not being listened to for many years.
Their voices have been instrumental in bringing these failings into the open. This report is, in many ways, a reflection of their persistence and their determination to protect others.
While nothing in this report can undo what they have been through, it is a step towards recognising and validating their experiences.
We know that, for many of our clients, this report brings mixed emotions, relief that their voices have been heard, but also the pain of revisiting what they have lost, and a natural uncertainty about whether the system can be trusted to change.
How do we respond?
At Nelsons, our ongoing focus will be on ensuring that the families we work with are supported, their voices continue to be heard, and that this report leads to meaningful and lasting change.
In our role, we also have a duty to keep this conversation going and continue to shine a spotlight on what needs to be done to protect families in our community.
The bravery of these families must lead to safer care for others in the future. This has to be a moment for real change, not just words, but action.
How can we help?
Shrdha Kapoor is an Associate in our Medical Negligence team, which is ranked in Tier One by the independently researched publication, The Legal 500, and Commended in The Times Best Law Firms 2024. She specialises in medical negligence claims, delayed diagnosis claims, and surgical error claims.
If you have concerns about the care you received, please contact Shrdha or another member of the team in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online form. We’re here to help you find answers and move forward.
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