The full, published report also takes us through a timeline of Nottingham University Hospitals (NUH) NHS Trust's maternity problems.

The review found that from 2010 onwards, a "series of indicators" began to emerge, which pointed to "underlying weaknesses in governance, leadership and organisational culture" within NUH.

These issues were identified through a combination of internal reporting and staff feedback.

The findings indicated there were already clear warning signs of "systemic weaknesses" within the trust dating back to the early 2010s.

"While each issue in isolation might not have indicated a system-wide failure, the culmination of issues over time should have prompted earlier and more decisive intervention," the review said.

Donna Ockenden has now concluded her second press conference of the day.

Donna Ockenden was also asked to elaborate on her comment from this morning's press conference that she would be “watching NUH really closely”.

She explained she does not want a repeat of a situation in Shrewsbury when families contacted her in 2022 - two years after her review of their maternity services - to say there had been no engagement since.

“I didn’t think I would have to go back [to Shrewsbury], but I did," she said.

“Myself and a very small team on a part-time basis will help the [NUH] to set up a process of learning and improvement.

“It’s going to be an ongoing process and I will continue to spend some time in Nottingham over the next 18 months to two years.”

Donna Ockenden has been answering questions from media at a press conference in the main function room of the Crowne Plaza Hotel.

She has been asked why she did not name the chief executives or the staff members who were involved in the bullying of maternity colleagues.

Ockenden said there was a balance to try to protect staff on the ground, who she praised for coming forward to share information in their hundreds.

She added it was “chalk and cheese” between the engagement of staff on the ground compared to the chief executives.

“We did the best we could, we got some very good staff engagement, but we recognise there are people who should have talked but chose not to… they won’t get away with it in future,” she said - a reference to plans to bolster rules around compelling NHS leaders to give evidence at upcoming maternity reviews in Leeds and Sussex.

“What we were told clearly from ordinary staff on the ground, over many years, they were raising concerns about safety, about staff burnout and they did not have the resources they needed," she said.

“But yes, there are gaps in our knowledge because people who needed to come forward did not.

“We don’t know why they didn’t engage.”

The inquiry details serious maternity failings at Nottingham University Hospitals NHS Trust dating back to 2010 - but who has been in charge over those years?

Dr Peter Homa served as chief executive from 2006, with his organisation categorised as a "high risk trust" by the Care Quality Commission in 2013.

After he stepped down in 2017, he was replaced by former nurse Tracy Taylor. A year later more than 50 maternity staff signed an open letter warning maternity services were in crisis.

Taylor left in 2021 and Rupert Egginton took on the top role on an interim basis before Anthony May took charge in September 2022 - a few weeks after Ockenden's review got under way.

May has pledged "transparency" and "full engagement" as the trust seeks to recover from the serious failings detailed in the review.

Canterbury MP Rosie Duffield, chairwoman of a parliamentary group on birth trauma, has echoed calls for a statutory public inquiry to stop the NHS "lurching from crisis to crisis".

She described maternity care as a "postcode lottery", with ad-hoc inquiries into failures at specific trusts failing to deal with a national problem.

She said: "It's really a question of how does your particular trust perform?

"Are you lucky enough to live somewhere where it's safer than somewhere else, which is awful?"

Local Labour MPs have issued a joint statement following the publication of Ockenden's review.

They say the report reveals "failures and harm that should never have happened, and identify issues that require urgent action".

The statement added: "Today is not the end of this process. It is the beginning of the next chapter.

"Our immediate focus is on the families at the heart of this review. We recognised that many will still be processing the findings and reflecting on what has been an emotional and deeply significant day.

"We want to give families the time and space they need and deserve. When the families are ready, we will meet with them again.

"We will listen carefully to their views and concerns, and together we will continue to advocate for whatever action is necessary to secure answers, accountability and justice they are still fighting for."

The statement is signed by Sherwood Forest MP Michelle Welsh; Gedling MP Michael Payne; Mansfield MP Steve Yemm; Erewash MP Adam Thompson, Nottingham North and Kimberley MP Alex Norris, North West Leicestershire MP Amanda Hack; Rushcliffe MP James Naish; Bassetlaw MP Jo White; Broxtowe MP Juliet Campbell; Nottingham South MP Lilian Greenwood; and Nottingham East MP Nadia Whittome.

Verity Cowley
Presenter, BBC Radio Nottingham

A total of 550 people involved in the Nottingham maternity review have been referred for psychological support.

Jen Moon (above), from the Family Psychological Support Service, said it would continue to accept referrals after the review had been published, and were able to offer a service to "anyone in the family who's been impacted by the Ockenden review".

Vinnie Irvine - who uses the support service - said he was traumatised after witnessing a complicated birth.

Speaking of the service, the father said he had learned techniques to "ground" himself when things start to "well up".

Nottinghamshire Police launched Operation Perth in September 2023 into failings that led to hundreds of babies dying or being injured.

Then, in June 2025, the force confirmed it had opened a corporate manslaughter investigation and said it was examining whether maternity care by NUH had been grossly negligent.

In January of this year, a member of police staff resigned after "deleting or altering" information as part of the investigation.

At the time, the force said an investigation found no evidence of misconduct, and determined the individual "did not act dishonestly or maliciously" and there was no evidence of third-party involvement.

The scope of Operation Perth was expanded in March to include potential offences committed under the Offences against the Person Act and the Abortion Act.

On Monday, police arrested two men in connection with operating practices in the city's mortuary service.

The men, 55 and 59, who were detained on suspicion of misconduct in the public office, were bailed on Tuesday.

On Wednesday, Deputy Chief Constable Rob Griffin added: "The publication of the independent maternity review report does not mark the conclusion of Operation Perth.

"We will consider the report's findings closely as part of our wider ongoing investigation."

Luke Mintz
World at One reporter

Sir Jeremy Hunt, the former health secretary, has said he fears Donna Ockenden's review into maternity care could be "yet another report that ultimately gathers dust", unless the NHS takes serious action.

Speaking to BBC Radio 4's World at One programme on Wednesday afternoon, Sir Jeremy said: "The NHS is the world champion at doing these reports and then not doing anything to implement them."

Asked about Ockenden's findings, he said: "The sad truth is that a lot more of this is common across the NHS than we might like to think.

"We're seeing a pattern now. It's time the NHS sets up a structured system so that when you have these public reports, when you have recommendations from select committees, from coroner's courts, something actually happens.

"That is the thing that is not happening at the moment. And unless that is addressed, I'm afraid this will be yet another report that ultimately gathers dust."

But Sir Jeremy also said he was "reluctant" to back calls for a full statutory inquiry in Nottingham maternity failings.

He said: "That's another five years, and that's another excuse for ministers to say 'well, we've got to wait until the public inquiry reports, and then we'll make our decisions'."

If you feel able to, you can get in touch in the following ways:

• WhatsApp: +44 7756 165803, external
• Upload your pictures and video
• Email: yourvoice@bbc.co.uk, external

Please read ourterms and conditions andprivacy policy.

In some cases, a selection of your comments and questions will be published, displaying your name and location as you provide it unless you state otherwise. Your contact details will never be published.

Lizzy Bella
BBC Newsbeat

Mollie Sutton has been waiting for the outcome of today's inquiry.

She believes mistreatment by medical staff during her labour at a Nottingham hospital in 2018 led to her son Rupert being disabled.

The mother of three, who is now 27, shared her experiences with Donna Ockenden's team.

"Throughout my entire labour, there was neglect and failures," she told BBC Newsbeat. "I was being verbally abused by my midwife, I wasn't given any privacy or dignity."

Mollie has been fighting for her son - who she said had the mental capacity of a four-month-old - for years and said she wanted the inquiry to lead to improvements.

"What we want and we really need is accountability and justice," she said. "We need change to happen fast."

Secondary victims of maternity trauma may be able to bring their own cases against trusts for mental health issues caused by their partners or their babies being injured or dying in delivery.

Health Secretary James Murray said he had spoken to families who had asked him to raise the issue.

He said: "Fathers, partners and others are actively encouraged to be present to support mothers through labour and delivery, however the law does not allow them to bring their own claims for the psychiatric illness suffered as a direct result of witnessing their partner or baby suffer injury or die."

Murray said he had asked barrister and former Labour MP David Lock KC, who is reviewing clinical negligence for the government, to work with civil servants on the issue.

The health secretary also said he would be speaking to the chief executive of NUH, Anthony May, next week to discuss the trust's response to the Ockenden review.

Pete Saull
Political correspondent, BBC East Midlands

Robert Jenrick, Reform UK MP for Newark, spoke in the Commons of constituents who felt like they "were being shooed out of a restaurant by a rude waiter" - moments after they had to say goodbye to their baby.

His reaction comes after an address to the House by Health Secretary James Murray, who earlier apologised for widespread failings on behalf of the NHS.

Joe McFadden
Health reporter

In its response to the Ockenden review, the government announced that anyone responsible for failures would be compelled to give evidence to investigations into poor maternity care.

But how will this work?

While statutory inquiries can compel witnesses to give evidence under oath, independent reviews do not have this power.

The government is suggesting they will use duty of candour laws in the Public Office (Accountability) Bill - also known as the Hillsborough Law Bill - which is currently going through Parliament.

The government intends to use this in the upcoming Leeds and Sussex maternity reviews, after some senior leaders refused to take part in the Nottingham review.

But it's still unclear how exactly this will be enforced.

The press conference held by the families has drawn to a close, but our reporter at the Crowne Plaza in Nottingham will be speaking to them separately shortly.

Michael Buchanan
Social Affairs Correspondent, BBC News

In November 2018, more than 50 staff at Nottingham's Queen's Medical Centre signed an open letter to health bosses warning the hospital's maternity services were in crisis and urgent action was needed.

The letter cited chronic understaffing, a scarcity of critical safety equipment and a "dire lack of leadership".

However, management reaction to the letter was "inadequate", its author told me recently. It was effectively ignored.

As the findings of the Nottingham maternity review reveals the shocking extent of mistakes that were made, what happened to that letter in 2018 goes to the heart of why maternity care in England is viewed as failing too many families.

• Read my full analysis: A letter sent by worried staff shows why maternity care is still failing too many families

Addressing the trust directly, Gary Andrews - whose daughter Wynter died 23 minutes after being born in 2019 - said: "If you'd listened to concerns, there would be hundreds of babies still alive.

"Wynter would still be here - and her brother would not be looking at a gravestone."

In 2023 NUH were fined £800,000 after admitting failings in Wynter's care. At the time it was the largest handed out to an NHS trust over maternity care.

Image source, PA Media

On the question of a statutory public inquiry - which would compel witnesses to give evidence and something the families have called for today - Health Secretary James Murray said: "I just want to be clear, no options are off the table."