MP to lead 'improvement board' after maternity failings

About 2,500 families and more than 800 staff members contributed to the review, which began in September 2022.

The independent maternity review, led by senior midwife Donna Ockenden, concluded there were "potentially avoidable" outcomes for mothers and babies in 520 cases.

It also found that different care may have altered the outcome for 260 babies - 155 who died and 105 who suffered serious brain injury due to substandard care - the review team told the BBC.

The review found the harm was rarely the result of a single issue or specific failing but was linked to multiple factors, including failures in monitoring babies, poor interpretation of heart monitoring, a failure to recognise babies were in distress during labour and a failure to escalate some cases to senior doctors.

Concerns of women were often dismissed and minimised and staff described racism and "racist attitudes towards black women labelled too loud, too demanding".

Leaders at the trust were aware of serious issues in its maternity department going back to "at least 2010", but failed to take action, the review found.

The report also identified a "bullying and toxic" workplace culture which stopped staff members from speaking up.

Health Secretary James Murray said the revelations of the review were "chilling" in an address to the House of Commons on Wednesday.

Murray also welcomed the appointment of Welsh as chair of the improvement board.

"This is a significant moment and recognises Michelle's tireless efforts campaigning to improve maternity and neonatal services, delivering real change for all families," he said.

The Learning and Improvement Board will be supported by two additional groups, one representing families and one representing staff.

Having led the review, Ockenden will co-chair the group representing families, alongside a family member.

She said: "I am so pleased to be remaining in Nottingham to support the ongoing perinatal improvement journey at NUH.

"The development of the Learning and Improvement Board fulfils a promise made to families that there would be continued scrutiny and improvement of maternity services at the trust.

"Its creation is also important to the more than 800 current and former staff at the trust who have engaged with the review.

"I am so glad that this is also an opportunity for their voices to continue to be heard."

NUH has been under close scrutiny since before the review began due to maternity failings, and has paid out £117m pounds in compensation, as well as being handed two record prosecution fines over the deaths of babies.

The trust said the new board would provide "independent check and challenge on the delivery of improvements".

Chief executive of the trust May, said the publication of the review was an "important milestone in a journey that must continue".

He said: "It is very important that we have robust, independent oversight of the implementation of the review's findings.

"We are committed to a comprehensive and sustained response to every action.

"Two years ago, we made a public commitment to ensure continued scrutiny of our maternity services, and this board is a key part of delivering on that promise.

"In the coming weeks, we will publish a detailed action plan setting out how every action will be addressed, with clear timescales and named accountability.

"We will continue to involve families and staff in shaping our response, and in holding us to account.

"We will work closely with the Learning and Improvement Board, NHS England, our regulators, commissioners, local families, partners and maternity experts to ensure improvements are delivered and sustained."

The trust said the board's terms of reference would be developed in partnership with families, staff and stakeholders and a first meeting would take place later in the year. It added progress updates would be shared publicly on a regular basis.

Additional reporting by Verity Cowley.