The Ockenden Report: How Many More Reviews Before Women and Babies Are Truly Safe? Joy Wisdom
How Many Maternity Reviews Do We Need Before Women Are Finally Heard?
The publication of Donna Ockenden's latest review into maternity services at Nottingham University Hospitals NHS Trust is both horrific, devastating and deeply familiar. It reveals what thousands of families have experienced, from failure of leaders and government from maternity scandals: avoidable deaths and injuries, women whose concerns were dismissed, toxic workplace cultures, failures in leadership, and attempts to conceal mistakes rather than learn from them. More than 500 mothers and babies were found to have suffered avoidable harm or death, while families repeatedly described not being listened to when they knew something was wrong, and our hearts go out to each and every one of them.
For me, this is not new.
In my first book, published in 2010, I wrote about these very issues because I heard the stories all the time from women. I highlighted the dangers of professionals dismissing women's instincts, the consequences of fragmented maternity care, and the urgent need for a more integrated, compassionate approach. Sixteen years later, reading yet another report describing many of the same failures. It seems emotional intelligence, has been lost to mechanism!
Now have the fourth major maternity review led by Donna Ockenden. Before that came other enquiries, including Shrewsbury and Telford, East Kent and Morecambe Bay. The pattern is painfully consistent: women not believed, families ignored, warning signs missed, staff afraid to speak up and organisational cultures more focused on protecting reputations than protecting mothers and babies, with accountability avoided within NHS trust reviews.
We cannot ignore the uncomfortable reality that misogyny still exists within parts of healthcare. Too often, women's pain, intuition and lived experience are minimised and ignored. Personal, cultural or religious beliefs must not override or influence clinical judgement or override evidence-based, individualised care. Every woman deserves to be listened to with dignity, respect and compassion as part of critical care.
The NHS is home to thousands of exceptional, dedicated professionals who provide outstanding maternity care every day. However, repeated enquiries demonstrate that where poor culture, bullying and complacency are allowed to flourish, patient safety suffers. Safeguarding our precious infants is paramount.
Calls for better systems, training, listening not only to families, but also to the staff who raise concerns. Have all fell on deaf ears. And it makes a nonscience of the reports, reviews.
The question is no longer whether leaders and government know what needs to change. They do.
How many more enquiries, reviews and bereaved families will it take before recommendations become routine practice? Action is required and required now.
It is time for a genuine cultural shift. That means stronger accountability, continuous professional development, integrated medicine that embraces physical, emotional and psychological health, and greater personal responsibility at every level of maternity care.
Because long term health issues are outcomes to parents and infants from poor birthing methods. Health risks in maternity care continue after birthing events. When maternity care fails, the consequences can extend across life, for the child, the parents, siblings and society. That point is reflected in evidence that babies who experience oxygen deprivation or other birth complications can have lifelong neurodevelopmental or physical disabilities, while parents may experience long-term psychological trauma, anxiety, depression or post-traumatic stress.
In this latest review Ockenden also highlights cases where failures in neonatal care may have contributed to long-term brain injury and neurodevelopmental outcomes.
Above all, it means toxic culture must change, placing women and babies, not organisations at the centre of every decision.
Every report has told us the same story. Talking is not enough… poor maternity practices and birth trauma happens daily and not acknowledged to the degree warranted. Adding to neglect women and their babies face. The outcomes are not a video game, reality is parents and children are being wronged daily and in large quantities and gone on for decades.
Talking is not enough…Action is required.
To urgently and finally, write a different ending.
Joy Wisdom
2026
Pregnancy and Birth Book in paperback, E book.
See videos on birth trauma:
https://www.youtube.com/watch?v=rznyi3_0JYE&t=5s
www.joywisdomtrust.org