Ockenden Maternity Review

The publication of the Ockenden Review into maternity services at Nottingham University Hospitals NHS Trust makes for deeply distressing reading. Our thoughts are with every family who has experienced the devastating loss of a baby or mother, or who continues to live with the lifelong impact of avoidable harm.

Above all, we recognise the courage and determination of the families who spent years campaigning to have their voices heard. Their experiences must remain at the heart of efforts to improve maternity care, and the recommendations of this review must now lead to meaningful and lasting change.

There were relatively few cases in which hypertension/pre-eclampsia were mentioned and in most of these it was felt that the care was either good or that changes in care would have been unlikely to to have changed the outcome (over 70%). Despite this, the report highlights several areas of concern relating to the recognition and management of pre-eclampsia and hypertensive disorders of pregnancy. These include failures to update local guidance in line with national recommendations on aspirin prescribing for those at increased risk of pre-eclampsia, insufficient fluid management, delays in responding to abnormal maternal observations (and recognising the urgency in taking action), and shortcomings in postnatal care and follow-up. These are not minor oversights – they are fundamental aspects of safe maternity care that can make the difference between timely intervention and serious harm.

Pre-eclampsia can develop rapidly and unpredictably. Early identification of risk, sharing information with the parents, adherence to evidence-based guidance, prompt recognition of deterioration, and appropriate monitoring before, during and after birth are all essential to improving outcomes for mothers and babies.

At Action on Pre-eclampsia, we remain committed to working alongside healthcare professionals, policymakers and, most importantly, families, to improve awareness, education and the implementation of best practice in the prevention, recognition and management of pre-eclampsia. We support the widespread implementation of PlGF use which is known to improve outcomes.

The findings of this report must serve as a catalyst for change – not only in Nottingham, but across all maternity services. This is not an example of “another bad trust” but a national concern, requiring national solutions. Every family deserves safe, compassionate, evidence-based care, and everyone deserves to have their concerns listened to and acted upon.