The Same Ward, A Different Body

Donna Ockenden’s name has appeared at the top of three of these reports now, which makes her less a one-off investigator and more something closer to a recurring diagnosis. This week the trust is Nottingham. Before that it was Shrewsbury and Telford. Before that it was East Kent. By the time you read this it might already be Leeds, where Ockenden was appointed in March 2026 to chair another independent review, which tells you everything about how confident anyone should feel that Nottingham was the last one.

I want to be careful here, because the instinct with a story like this is to reach for the cold, clean facts and let them do the talking, and they will, because the facts are genuinely obscene. But facts without anger are just data, and I’m not interested in writing data. So let’s do both.

The facts first, since you’ll want them as the spine. The review considered the quality of care relating to newborn, infant and maternal harm at Nottingham University Hospitals NHS Trust, based on over 2,500 family cases. More than 160 reviewers took part, holding individual meetings with over 500 families, while more than 830 current and former staff engaged with the process. Out of that, 2,505 cases were examined in total, spanning stillbirths, neonatal deaths, severe brain injuries, severe maternal harm and maternal deaths, making it the largest review of a single NHS service in the country’s history. Somewhere in the region of two hundred and sixty babies died or were left permanently harmed by care that, had it been competent, might have gone differently. That’s not my framing. That’s the trust’s own commissioned review telling the trust what the trust did.

What I keep returning to, though, isn’t the number. Numbers are how institutions absorb horror without having to feel it, which is itself part of the problem this report describes. What I keep returning to is the phrase Ockenden used to describe how this kind of failure becomes normal: the “normalisation of deviance” in maternal care. It’s a phrase borrowed from systems theory, originally used to explain how organisations slide, case by case, decision by decision, into accepting outcomes that would have horrified them at the start. Nobody at Nottingham woke up one morning and decided that babies could be treated as acceptable collateral. It happened the way these things always happen… an inch at a time, a shrug at a time, a closed door at a time, until inches became the whole mile and nobody could quite say when it had started.

And the door-closing was deliberate, or at least it was structural enough to function as if it were. Women were dismissed. One mother, worried that her baby had stopped moving as much, was told, in essence, that this was just first-time-mother anxiety. She would later say she’d been left with the impression that the staff thought it was simply her own fault for being busy and anxious, and that she hadn’t known what was normal because the baby was her first. That’s not a clinical failing. That’s a person who raised a concern about her own child’s life and was handed back her own self-doubt instead of medical attention.

There’s a particular cruelty, too, in what happened after some of these babies died, which is the part of the story that tends to get skipped over because it’s almost too grim to sit with. In 2019, an early-gestation baby was inadvertently disposed of as clinical waste by laboratory staff following her post-mortem examination, against the explicit wishes of a family who had been clear they did not want this. I’ve read that sentence three times now and it still doesn’t sit right in my chest, and it’s not supposed to. There’s no register, satirical or sombre, that makes that sentence easier to carry. You just carry it.

The report also names what a lot of NHS scandals tend to gesture at without quite saying outright, which is that race was a factor in who got listened to and who didn’t. Black women were, by staff’s own account, characterised within the trust as “too loud, too demanding”, and women whose first language wasn’t English were left without adequate communication support at precisely the moments they most needed to be understood. None of this happened in a vacuum. It happened inside a workplace culture the review itself describes, in language unusually blunt for an official report, as bullying and toxic, governed by cliques that were well known internally and never confronted, because confronting them would have meant someone with power admitting that the “Nottingham way” wasn’t working.

Here’s where I’d usually find the satire, the Unharnessed register, the bit where I point at the absurdity and let it indict itself. But I want to hold that back for a paragraph, because there’s a structural point that matters more than the joke. This is now the third major maternity scandal of its kind to come out of the English NHS in under a decade, and Ockenden herself is the connective thread, having already led the inquiry into Shrewsbury and Telford before this one, and having since been handed Leeds as well. At what point does a recurring pattern stop being a series of isolated institutional failures and start being evidence of a system that simply does not protect women and babies as a structural default, only as an occasional act of individual heroism by an overstretched midwife who happened to notice in time?

That’s the bit that should make you angry in a useful way, rather than a despairing one. Because the despairing version of this story is “the NHS is broken, nothing changes, here we go again,” and that version, while emotionally honest, lets everyone off the hook by making the failure feel inevitable. It wasn’t inevitable. Leaders at the trust knew there were serious issues in its maternity department going back to at least 2010, which means somebody, somewhere, in a meeting room, with coffee going cold in front of them, looked at the early warning signs and decided that addressing them properly could wait. That decision, repeated by enough people over enough years, is what builds a system that disposes of a baby as clinical waste and writes it down in a file as an administrative error.

There is, at least, a criminal dimension finally catching up to the institutional one. Nottinghamshire Police launched Operation Perth in 2024, formally escalating it to a corporate manslaughter investigation by June 2025, examining whether NUH as an organisation bears responsibility for the deaths and serious injuries in its maternity services. As of earlier this year, investigators had reviewed 232 of 360 family folders referred to them by the Ockenden team and were consulting the Crown Prosecution Service on a number of cases. Whether that goes anywhere is an open question I’m not going to pretend to predict. But it’s worth noting as a marker of how far this has travelled, from “service failing” to “corporation potentially liable for manslaughter,” because that’s the distance between an apology and an accounting.

The trust did apologise, for what it’s worth, and not in the usual mealy-mouthed corporate register either. “We failed you, and on behalf of Nottingham University Hospitals Trust, we accept responsibility of our failings,” they said. I believe that they meant it, in the moment, in the room, in front of the cameras. I just don’t believe a sentence like that, however sincerely delivered, is the thing that stops the next trust sliding into the same normalisation of deviance five or ten years from now. Sincerity isn’t a systems fix. It’s a feeling, and feelings don’t show up on a CTG monitor at three in the morning when there’s one midwife covering a ward built for two.

I don’t have a tidy way to close this, and I’m not going to manufacture one. Ockenden has now done this three times. There will, on current form, be a fourth, and a Nottingham of some other name will get its own report, its own digits standing in for children who didn’t get to grow up, its own press conference where someone says the right words to a room full of people who’ve already heard them said somewhere else, about someone else, not nearly long enough ago.

Until Next Time