Reflecting on the Findings of Donna Ockenden's 2026 Reviewā
āThe findings fracture my heart. Overall, 520 mothers and babies suffered potentially avoidable harm, with 162 of them dying after experiencing substandard care."
A Midwife's Reflection on the Human Cost of Failure
Let us imagine a summers day at a local zoo for a one-on-one animal encounter. A family arrives with absolute trust and excitement for their once in a lifetime experience with a beautiful animal that they love. They fully expect the experts behind the gates are keeping them safe. But behind the scenes, it has been deliberately hidden that the animal is highly volatile and dangerous. The safety fences have been rotting since 2010, the zookeepers are severely understaffed, and they are bullied into silence by management if they try to point out the risk. The moment the encounter begins a catastrophic attack occurs, altering the familyās lives forever.
Instead of rushing to help, the zoo directors blockade the gates. They hide the incident logs, and they spend over a decade ignoring the familyās cries for answers. When independent investigators finally force their way inside, some of the top directors flatly refuse to cooperate. The investigation reveals that the zoo is spending almost as much in legal compensation for injuries as it does running its service.
Sounds awful, doesnāt it?
That is the devastating reality of our maternity services as per Donna Ockendonās report released today.
When Maternity Care Fails
As a midwife who works in the medico legal field, specialising in complex birth and child brain injuries, I spend my life analysing the aftermath of these systemic collapses.
Todayās review into Nottingham University Hospital NHS Trust isnt just about statistics. It is a reflection of a total collapse of human purpose. The report outlines a terrifying scale of life-long physical and psychological trauma, including 94 stillbirths, 62 neonatal deaths and the deaths of 6 mothers.
For the babies that survived but were left with permanent neurological disorders like cerebral palsy, the report reveals that 50% of the cases involving HIE could have been avoided with better care. Half of those babies would be healthy and without lifelong disability today if the system had simply listened to their mothers.
The report exposes that only 11% of staff felt they had enough colleagues to do their jobs safely with over 40% of staff witnessing or experiencing bullying. The culture of evasion was so deep that senior leaders refused to take part in the review, forcing the government to introduce a two-year prison sentence for anyone who deliberately withholds information in future inquiries.
Most sickeningly and beyond upsetting to read is that the disregard for human life extended into the mortuaries, where investigators found a recurring failure to protect the dignity of deceased babies, including a little one tragically disposed of as clinical waste.
The government has announced the rollout of Martha’s Rule, giving parents a helpline to demand an urgent second opinion if they see their loved one deteriorating, a monumental step but a bittersweet milestone to reach. Families should not have to carry the burden of policing their own medical safety because the professionals in the room refuse to listen.
The trust’s leadership has issued an unreserved apology.
Today it is re-iterated that when the system protects itself instead of the patient, it costs exactly what Donna Ockenden stated before the room fell into a minute of silence. It cost lives, futures, and families, everything.
As we continue to unpick these tragedies with families every day, analysing the precise, agonising seconds where a HIE injury has been allowed to occur, I will continue to advocate for the accountability that these families deserve, calling out the avoidable gaps and standing as a voice for the babies whose futures were rewritten in the dark.
How Brain Injury Group Can Help
For families affected by birth injury, hypoxic-ischaemic encephalopathy (HIE), cerebral palsy or other neurological conditions, accessing the right support can be overwhelming. Brain Injury Group brings together a network of specialist professionals, providing access to trusted legal, rehabilitation, therapy and support services, alongside practical resources designed to help families navigate life after injury.
To find support or learn more, visit www.braininjurygroup.co.uk.
