Inquiries Find Substandard Care Contributed to Maternal Deaths at England Hospitals

Two inquiries released last week found that substandard care at hospital trusts in England contributed to a rise in maternal and neonatal deaths. The Ockenden report examined practices at Queen’s Medical Centre and Nottingham City Hospital and concluded that 444 women and 76 newborn babies suffered potentially avoidable outcomes over 13 years at Nottingham University Hospitals Trust.

The three-year review, led by midwife Donna Ockenden, looked at the deaths of 27 mothers in the Nottingham area between 2006 and 2024.

It identified failures in listening to families, continuity of care, clinical governance, and prompt access to imaging. The report also documented a bullying culture, senior managers who did not act on repeated warnings, routine turning away of women in labour, and understaffed units.

A separate Amos report reviewed 12 maternity and neonatal services and found racism and discrimination embedded throughout the system.

Women and families reported unequal treatment, racial slurs, Islamophobia and antisemitism, while staff described similar experiences. On 30 June 2026 Health Secretary James Murray called the Amos review a watershed moment and announced a new statutory maternity and neonatal commissioner role accountable to Parliament.

He also pledged £41 million to improve safety, create 1,000 temporary midwifery posts, and publish new national standards for emergency maternity care.

Oxford University research published in January 2026 showed the UK maternal mortality rate for 2022-2024 reached 12.8 deaths per 100,000 maternities, 20 percent higher than 2009-2011. MBRRACE data recorded 252 women who died from direct or indirect causes during or soon after pregnancy among 1,969,321 maternities in the same period.