NMC to play its part in meaningful and lasting change following Nottingham maternity review

The NMC recognises that in the past it was too difficult to access, and too slow to understand the depth of the concerns being raised – failing many families, whose tireless campaigning is helping to ensure those responsible are held to account.

In total more than 2,500 families are living with loss, serious harm and trauma – with multiple compounding and repeated failures across the Nottingham maternity service leading to poor outcomes.

The regulator has learned lessons – under new management it has actively engaged and listened to families and made changes.

Based on the feedback, the NMC has held six face-to-face case surgeries and a series of virtual sessions attended by 70 affected families, to enable them to discuss their experiences with the regulator – enabling it to explore the best way forward for each case. As a result of the surgeries, 57 Fitness to Practise (FtP) cases were opened.

The cases are being managed by the restructured Sensitive and Complex Casework Team – a specialist FtP team that the NMC has invested in to ensure senior oversight and timely resolution of sensitive cases, including those connected to Nottingham.

The NMC is also ensuring that there is now earlier clinical advice and public support advice for these cases – as a result the cases are progressing as quickly as possible.

Also based on families’ feedback, and with support from Donna Ockenden, the NMC is improving public information, to support women and their families to know what to do if something in their maternity care goes wrong.

The NMC has taken regulatory action in Nottingham to protect the public. It currently holds a total of 96 FtP cases relating to maternity care at Nottingham University Hospitals NHS Trust. Of these, 80 are at Screening, the initial assessment stage of the process. A further 15 are currently undergoing full investigations. One case has been investigated and is at the Adjudications stage – where a determination will be made about whether the individual’s fitness to practise is impaired.

For the midwife whose case is at the Adjudications stage, there is an Interim Order in place – meaning that they are currently unable to practise while FtP proceedings are ongoing.

Some of the findings of the Ockenden report echo previous reviews: poor communication with women and families, not recognising deterioration, and failing to escalate effectively – all against the backdrop of chronic workforce pressures and poor working culture.

The review also highlights the ongoing injustices of maternal health inequalities, with Black, Asian and ethnic minority women from the ethnically diverse Nottingham population – as well as those from poorer backgrounds – receiving poor care.

These findings underline the importance of organisations and the wider health and care system actively addressing what more can be done to ensure safe, equitable and person-centred care for all. To that end, the NMC recently published its new anti-racism principles to urgently tackle the health inequities suffered by racially minoritised people. The principles, designed to tackle the Black maternal health crisis, outline ways educators, organisations, registrants and employers can address the growing concerns around inequities in care and racism across health and social care practice, education, and regulation.

Given the scale, seriousness and profound impact of these failings, it was vital that they were subject to such a thorough review by Donna Ockenden – the largest of its kind in NHS history. The NMC welcomes the report and the learning it has taken from engagement in the inquiry.

The publication of Ms Ockenden’s report and the immediate and essential actions she recommends is a landmark moment for families, many of whom have spent years seeking answers and accountability. The NMC pays tribute to their courage, determination, and persistence in bringing these issues to light.

The NMC agrees that light needs to be shone on the role of regulators to build back lost trust. It will now play its part in delivering the actions from Ms Ockenden’s review – for example, working with its partners to support the delivery of a national perinatal standard for education, and making sure that all midwives can recognise when labour goes wrong and escalate effectively.

The NMC also wishes to pay tribute to Ms Ockenden and her team for their tireless work and thorough examination of the issues, and for ensuring that families have been at the heart of this review throughout.

Paul Rees MBE, Chief Executive and Registrar, said:

“The experiences shared by families through the Nottingham maternity review are deeply shocking in describing harm and loss that should never have happened. Hearing directly from families reinforced the need for the NMC to change how it listens, acts and responds effectively when concerns are raised. We are committed to ensuring that the findings of this review continue to shape and strengthen our work, driving improvements in accountability, public protection and trust.

“I’m clear that the NMC of the past was too remote and too slow to recognise the depth of the issues in Nottingham – failing families as a result. We’ve apologised to families in Nottingham.

“The new NMC has listened and changed how we engage with families, and how we use the information they’ve shared, taking a family first approach. We are encouraged by the feedback we have received that reflects the importance of these changes and the difference it makes for families. While we recognise there is still more to do, we remain committed to listening, learning and taking action, and to playing our part in meaningful and lasting change that helps deliver safer maternity care for all.”

The NMC welcomes the publication of the Nottingham maternity review and will carefully consider its findings and recommendations in full.

Other recent news…