Submission to the Ockenden Maternity Review

Submitted to the Review team on 13/05/2026

As the regulator for midwifery, the NMC continues to work with, and learn from, the various reviews of maternity across the four countries of the UK, including the review into maternity services in Nottingham. The NMC has not always met the needs of families and is clear that we need to continue to learn from feedback, we are grateful for all of the families who have taken the time to share with us what has happened to them and their feedback on working with the NMC.

Ensuring families voices are central to our work

Based on feedback from families and with support from Donna, the NMC has also produced a new leaflet to support women and their families in what to do if something in their maternity care goes wrong. The NMC have shared this leaflet and QR code with PALS teams and national organisations to enable them to support and inform families about the NMC and our role.

Ensuring our engagement with families is trauma informed

Any NMC colleagues working on the Nottingham review have received training in trauma informed approaches, through the service that supports families in the review.

Increasing visibility of the NMC

We held seven case surgeries in Nottingham which gave families the opportunity to speak to us individually or jointly to raise their concerns, without having to repeatedly discuss what has happened to them. We have also attended several family meeting days in Nottingham to share information about our role as a regulator, and our progress on Fitness to Practise cases. We have spoken to local media at these events to further increase awareness of our role. This is to ensure that we are visible and accessible to families who wish to raise questions or concerns.

Improvement and timeliness in Fitness to Practise

The NMC has made a number of changes as a result of feedback. In response to concerns that we have taken too long to make decisions at screening, we have redistributed our caseload to ensure, as much as possible, that the same staff members manage all cases related to care at the Trust to ensure coordination and identification of any trends. The NMC is routing all cases related to Nottingham through our Sensitive and Complex Casework team which has succeeded our previous Major Investigations Team. This central management of all cases is ensuring central and more timely management of related cases. We have also introduced wraparound support measures to support case management, including early clinical advice and public support service advice.

The NMC has also undertaken work to review 336 family forms provided by the Review team outside of the normal referral process. This is something the NMC has never done before, as this is outside of our rules. However, we agreed to look through the forms due to the exceptional circumstances because we know that we need to leave no stone unturned and to understand what’s happened, including by looking across multiple cases.

The Fitness to Practise process is about taking action against nurses or midwives who are seen as posing a risk to public safety in the future. As defined in our rules, it is not about punishing people for past events.

The NMC is working had to improve Fitness to Practise and have improved our timeliness rate to 74% of cases being resolved within 15 months. The NMC has developed a midwifery data dashboard- which is available on our website- which provides information about the numbers and types of Fitness to Practise referrals we receive about midwives. This provides greater clarity and transparency about the issues that have led to referrals of midwives into our process.

Working with partners

The NMC have also undertaken wider engagement activity, and we’ve been working with organisations including Healthwatch, PALS and National Voices to share information about the NMC, so that this information can be shared with women and their families in cases where something goes wrong in their maternity care.

Education partners

In addition, based on feedback from the families, the NMC has directly engaged with midwifery students in Nottingham, to ask them about their experiences of education, both at the university and in their practice placements. The NMC has also undertaken a comprehensive curricula mapping exercise to look at the prevalence of the concept of ‘normal birth at any cost’ in university programmes. We found that no universities were promoting ‘normal birth at any cost’ in university programmes.

However, there were a minority of institutions who were too reliant on ‘normal’ phraseology in their materials. We also found that the recommended reading lists of some institutions contained materials that could be seen to promote ‘normal birth at any cost’. While it is important that universities teach midwifery students about ‘normal’ physiology, as part of the training to understand when things are going wrong, we will be writing the institutions to review their over-reliance on normal phraseology and also to look at updating their reading lists.

Working with Trusts

The NMC have published internal culture of curiosity guidance which sets out what we expect of all NMC colleagues to ensure they are sufficiently critically appraising information and asking questions when receiving information. We also engage regularly with Trusts, requesting supporting information where needed, and providing training for the Trust to outline our processes and how we can provide pre-referral advice and support.

Tackling racism

Meanwhile, tackling racism in maternity services is a key priority for the NMC. In the next few weeks, we’ll be consulting with stakeholders on developing principles for universities to teach midwifery students about anti-racism, cultural competence and unconscious bias awareness by September this year.

Conclusion

We were too slow to respond to the situation here and it took us too long to see that we needed to work differently. It’s clear that we needed to learn from your feedback earlier on – and to make changes to the way we do things.

We have to do better – and we’ve made a number of changes as a result of your feedback. We are determined to put into actions the lessons we’ve learned in Nottingham and to continue to learn and apply this in other places.