MP Michelle Welsh To Chair Learning And Improvement Board After ‘Deeply Embedded’ Failings At Nottingham Maternity Unit

The independent review into Nottingham University Hospitals (NUH) NHS Trust has concluded that "deeply embedded systemic failures" in its maternity services contributed to deaths and avoidable harm to mothers and babies. Labour MP Michelle Welsh — the government's first national maternity adviser and a mother who experienced serious problems at NUH — will chair a new Learning and Improvement Board to oversee reforms.

Families took part in a minute's silence to mark the end of review lead Donna Ockenden's speech at a press conference on Wednesday [PA Media]

Key Findings

The Ockenden-led review, which began in September 2022 and involved about 2,500 families and more than 800 staff, identified 520 cases with potentially avoidable poor outcomes. Investigators concluded different care might have changed the outcome for 260 babies: 155 deaths and 105 babies who suffered serious brain injury linked to substandard care.

NUH chief executive Anthony May (right) and the chairman of the trust Nick Carver (left) attended the press conference [PA Media]

Recurring Failings

• Poor fetal monitoring and interpretation of heart traces.
• Failure to recognise babies in distress during labour and to escalate concerns to senior clinicians.
• Dismissal or minimisation of women’s concerns.
• Reports of racist attitudes toward Black women and a bullying, toxic workplace culture that discouraged staff from speaking up.
• Leadership that was aware of problems dating back to at least 2010 but failed to take adequate action.

Required Actions And Trust Response

The review set out a list of urgent actions for the trust. NUH has already paid around £117 million in compensation and has faced two record fines following prosecutions related to baby deaths. The trust says it will publish a detailed action plan with named accountability and timescales and provide regular public progress updates.

Kim Errington said although the board was chaired by "fantastic people", it alone would not "solve the problem" [BBC]

Immediate priorities include:

• Strengthening risk management, fetal monitoring and escalation pathways.
• Improving neonatal safety and clinical care.
• Providing better psychological support for affected families.
• Reforming governance, leadership and workplace culture to ensure transparency and a safe environment for staff to speak up.

Oversight, Families And Next Steps

The Learning and Improvement Board, chaired by Michelle Welsh, will be supported by two advisory groups representing families and staff. Senior midwife Donna Ockenden, who led the review, will co-chair the families' group alongside a family representative. The trust says the board's terms of reference will be developed in partnership with families, staff and stakeholders, with a first meeting planned later in the year.

Health Secretary James Murray described the review's revelations as "chilling" and welcomed Welsh's appointment as chair.

Many families remain sceptical that a board is enough. Campaigners and bereaved relatives have called for a statutory public inquiry into maternity services across England to get to root causes and prevent further harm.

What To Watch For

• Publication of NUH's detailed action plan with clear timescales and named leads.
• Regular public updates from the Learning and Improvement Board and independent oversight of progress.
• Decisions on whether a statutory public inquiry will be launched.

Additional reporting by Verity Cowley.