A review intended to drive 'rapid improvements' to maternity services in Nottingham has been scrapped after just eight months – with some bereaved families saying instead it did 'irreparable' damage to their mental health and trust in the system.

Instead, the NHS announced experienced midwife Donna Ockenden – who led an in-depth review into Shrewsbury and Telford NHS Trust's maternity services, will start a fresh review in Nottingham.

The U-turn comes after pressure from a group of more than 100 people named 'Families Harmed by Nottingham Maternity' – which includes parents whose babies have died or been injured while being cared for at Nottingham's two main hospitals.

Local Democracy Reporter Anna Whittaker looks at what led to so many families turning on a system which the NHS said was set up to bring about major changes.

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In October 2021, a review was set up to look at 'maternity incidents, complaints and concerns' at Nottingham University Hospitals Trust's two main sites, the Queen's Medical Centre and City Hospital.

It was hoped the process would lead to rapid change, restore families' faith in maternity in Nottingham, and provide a voice for parents who wanted to share both positive and negative experiences.

Instead, some families said they found the review process slow, unprepared for the number of people who came forward and lacking the impact needed to improve a maternity service rated 'inadequate' by health inspectors.

The growing frustration that followed would turn to anger for some families, leading to the direct involvement of a Government minister, the arrival and rapid departure of a new chair, and the eventual disbanding of the review altogether in favour of a fresh start with one of the country's top advisers on midwifery.

When it started, the Independent Thematic Review into Nottingham University Hospitals (NUH) maternity services, was brought in as a remedy to ongoing problems which had led to dozens of incidents involving baby deaths and injuries. As a result, the NHS had also paid out millions of pounds in compensation to some families, dating back more than a decade.

The review was jointly commissioned by the local NHS Clinical Commissioning Group (CCG) and NHS England / Improvement – but some parents had doubts early on, questioning the review's leadership and why more families were not coming forward.

The review set out to cover information dating back to 2006, and was due to be complete in November 2022.

At first, the number of families coming forward to share experiences with the review team slowly crept up – by the end of November 2021, around 50 families had contacted the team, which had ten staff overall.

On March 25, the review team emailed out an update, which went to a number of contacts including members of the media, saying the number of families who had come forward increased from 84 to 387 in two weeks.

It meant in some cases members of the media found about the increase before families, in what parents said was described to them as a "process error".

The review team said the increase in families coming forward was "directly linked to social media advertising", which followed claims from some bereaved parents that the team was not doing enough to encourage more families to come forward.

Jack and Sarah Hawkins, whose baby Harriet was stillborn in 2016 at Nottingham City Hospital, said: "When the numbers shot up it was of no surprise to us.

"But it was absolutely shocking that there was never a dedicated hotline, a Twitter profile or Facebook page for people to come forward to."

By May 17, 590 families had come forward to share their experiences with the review.

Jack and Sarah Hawkins, whose baby Harriet was stillborn in 2016 at Nottingham City Hospital, were critical that the review didn't have a dedicated hotline or social media presence. Image courtesy of LDRS.

The new review chair steps down

On April 22, a Friday afternoon, NHS England and NHS Improvement chief operating officer Sir David Sloman, announced a new chair would be put in place to lead the review.

Before this point, Cathy Purt, an experienced NHS manager and non-executive director at Shropshire Community Health NHS Trust, had led the review as programme director.

Mr Sloman said Julie Dent, an NHS Trust Chair, would lead the review with immediate effect – a move publicly backed by Health Secretary Sajid Javid, who said he was confident she would "deliver a review that helps address these tragic failures".

But some of the harmed families released a statement saying they had been "severely let down, confused, and further traumatised" by the announcement, which was made late on a Friday, and without prior consultation with them.

They requested Ms Dent decline the offer. She stepped down less than a fortnight after the announcement, citing personal reasons. 

So serious was the situation that seven Nottinghamshire MPs wrote a cross-party letter to Mr Javid saying they felt the review was "not fit for purpose".

Families then faced 21 days with little update after Ms Dent stood down.

Many of these parents used social media to campaign for experienced midwife Donna Ockenden to take over – sharing personal photos of their babies on Twitter to appeal for the Government to step in.

"Anyone going to put us out of our misery? Waiting for the interim report is living hell. Do we just hunker down for another horrendous night of nightmares and broken sleep?", asked Sarah Hawkins, in one tweet on May 24.

It wasn't until May 26 that Mr Javid made a call to Jack and Sarah to give them the news that Ms Ockenden had been appointed.

At the same time, David Sloman wrote to families and apologised for the "distress caused by the delay" and asked that the existing review team conclude their work by June 10.

Families described their "immense sense of relief" in a joint statement.

The review becomes 'untenable'

Emmie Studencki and Ryan Parker's baby Quinn died at City Hospital in July 2021.

The couple shared their devastating experience in a 'listening session' with the review team in January.

They say they were not offered psychological support until February 2022 – despite the review team previously saying that a listening session could not take place until it ensured "psychological support is in place if necessary".

They added that they found it hard to contact the review team on the phone and rang 'at least 15 times in the last six months and couldn't get through', simply getting a dead tone at the end of the line.

The couple said it "didn't sit right" with them that the review was also accepting positive experiences, given the huge numbers of families who came forward.

"The key to successful long-term change is developing a relationship with harmed families, built on trust, sensitivity and understanding", Ryan and Emmie said.

They said the relationship between the review team and families had become "untenable" before the process was scrapped.

Despite the uncertainty over the review's future, in mid-May the team told families that they would be publishing an interim report, but did not initially say when it would be released.

It was made public on May 26, and made a series of recommendations to NUH.

It said there had been 'unacceptable behaviour' by some members of maternity staff, creating a "defensive and fractious culture".

NUH says it welcomes the report and is acting on the findings, while it remains ready to work with the new review.

Claims review team were 'defensive and chaotic'

Gary and Sarah Andrews were also part of the group of families who urged the Government and NHS England to scrap the original process.

Their baby daughter Wynter died at the Queen's Medical Centre in 2019 after what a coroner described as "a clear and obvious case of neglect".

Gary said he felt the review team were "defensive and chaotic" during the process.

He added the news of the interim report would be "at the detriment of our mental health", and would cause "significant distress to families".

He also questioned why the review only included experiences from staff who currently worked at NUH or had worked for the trust in the most recent 12 months.

He said the review team continued with the approach "despite our warnings that there was information available to indicate staff were unhappy even in 2018", a comment which refers to a whistle-blowing letter from midwives to trust managers outlining concerns over staffing levels.

Sarah Andrews with baby Wynter. Image courtesy of LDRS.

Jack and Sarah Hawkins told the Local Democracy Reporting Service they "immediately" had doubts about the review when they found out that the terms of reference had been finalised without families' input back in summer 2021.

They added: "We want an apology and an explanation. Who is going to step up and apologise to families?

"Nobody has come forward to ask what could be learned from this.

"There was more than enough information to have stopped the review, but there was an attempt to keep on pushing through with it.

"It was a horrible thing to put people through."

Health secretary says no families should experience the same pain again

David Sloman, Chief Operating Officer at NHS England and Improvement, said: "We know we need to get this right for the families who have experienced such terrible loss and been through so much pain already.

"We have listened to the concerns raised and we want to ensure the new review addresses them – it must support families to share their views and their experiences so that vital improvements can be made for mums, families and babies in Nottingham.

"Given Donna Ockenden's wealth of experience, we are pleased that she has agreed to chair the review – we will start work together now to develop the terms of reference so that her vital work can begin without any further delays.

"The NHS is absolutely committed to ensuring that the new review delivers much-needed improvements to maternity care for families across Nottingham."

Health and Social Care Secretary Sajid Javid added: "It's absolutely vital that mothers and babies have access to the best possible care and I was deeply moved by the stories of families who have suffered from these tragic failings – my sympathies remain with all of them.

"We will continue to take all the steps necessary to ensure no families have to go through this pain again".

Sharon Wallis Director of Midwifery at Nottingham University Hospitals said NUH are "passionate about improving our maternity care".

She added that they will work through the interim report's recommendations and thanked families and staff who took part in the process.

The review team said as their work had ceased, it was not appropriate to comment further.