Horrific failings led to 520 mothers and babies in Nottingham suffering harm or dying, sparking calls for a public inquiry into maternity care across England.

In all, 444 women and 76 newborn babies suffered “potentially avoidable” outcomes, a damning three-year long review of the biggest childbirth scandal in NHS history concluded.

James Murray, the health secretary, said the nature and scale of the failings exposed by Donna Ockenden’s report on maternity services at Nottingham University hospitals NHS trust (NUH) between 2012 and 2025 were “horrific” and “chilling”.

Families suffered “dangerously and tragically deficient care at almost every turn” and “the NHS failed them catastrophically”, said Murray. He was “devastated” and “heartbroken” to read Ockenden’s 401-page account of the “neglect, incompetence, racism, discrimination, contempt and harassment that so many suffered”.

Ockenden, a respected maternity safety expert, painted a stark and detailed picture of maternity care at NUH’s two hospitals, Queen’s medical centre and Nottingham city hospital. “Multiple” women experienced dangerously poor and sometimes “cruel” care there, understaffing was routine, lessons from patient safety incidents were not learned, and bullying by “intimidating cliques” of staff was rife, she found.

The Nottingham Maternity Families group, which represents about 600 harmed and bereaved families, asked Keir Starmer to establish a statutory public inquiry to investigate failings in maternity and neonatal care across the entire NHS “because safe care can only be consistently delivered when the full truth is known”.

The government is considering that request, Murray said. “I don’t think we should take anything off the table at this stage,” he said when pressed on the possibility of such an investigation.

But he stressed that affected families do not all support such a move. “When I’ve been talking to families, some want a public inquiry, others take a different view, but what unites all of the families I spoke to is a desire for accountability and a desire to see change happen in the way maternity services are delivered so that women are listened to,” he said.

Ockenden and her team of maternity experts investigated the deaths of 27 mothers between 2006 and 2024 and “identified failures in care that may have or substantially impacted on the outcome in six deaths”.

Staff not listening to women or acting promptly on concerns they raised was one of the “common failures” involved in maternal deaths, they found, as well as delays in women having scans.

Sajid Javid, the then health secretary, ordered the review in 2022 after families warned that maternity care at NUH care was unsafe. It also examined cases in which babies died as a result of being starved of oxygen during birth or from a hospital-acquired infection, or because midwives and doctors did not manage the mother’s labour properly or provided poor postnatal care.

Detailed examinations of the deaths of 31 newborn babies concluded that they had received inadequate care and that, if they had been handled differently, they would probably have avoided coming to harm.

The report lays bare a host of recurring failings in clinical care that put mothers and babies at risk and in some cases had catastrophic consequences. They included repeated failures to monitor babies properly during labour, misinterpretation of CTG trace-reading of the baby’s health while still in utero, not recognising when babies were in distress, and midwives not escalating worrying cases urgently to doctors to make rapid decisions on the care and treatment needed.

“In a number of cases these failures contributed to severe neonatal injury, stillbirth and neonatal death,” the report says.

In all, 2,536 families and 838 current or former NUH staff gave evidence to the review team. It also found that:

• A “bullying and toxic culture” persisted at NUH over many years and impeded moves to improve care.

• Maternity service managers and the trust’s senior leaders were repeatedly warned about a host of serious problems in the maternity units at both hospitals but did not take effective action.

• Maternity staff displayed “a culture of not admitting women who were seeking admission in labour”, despite the risks this posed to them and their babies.

• Both maternity units were consistently seriously short-staffed and could not cope with the number of births and complexity of cases they had to handle.

• One baby girl who died early in gestation was “inadvertently disposed of as clinical waste by laboratory staff after her postmortem examination”, compounding her parents’ distress.

Families told Ockenden about horrific experiences they had. Some were denied pain relief, or given too little. “It felt brutal … traumatic … They were screaming at me: ‘You need to pull yourself together,’” one woman said.

In behaviour that Ockenden said was sometimes “cruel” and lacking compassion, staff could be dismissive of women’s concerns. One said she was told: “Is this your first baby? Take some paracetamol and have a hot bath.’”

The Nottingham Maternity Families group said the need for a full public inquiry, with the power to compel witnesses to attend, was underlined by the “appalling” refusal of so many senior figures, in the trust and local NHS bodies who were overseeing it, to talk to Ockenden.

Almost half the 66 current and former NUH executives it asked to engage with the inquiry did not do so, despite many being asked “on multiple occasions”. The response was even worse among leaders in the NHS clinical commissioning group and integrated care boards – only four of 14 contacted did talk.

Ockenden described the trust as dysfunctional, badly run and determined to hide from public view the dangerous truth about care in its maternity units.

The families also described as “appalling” the fact that many NUH senior managers chose not to give evidence to the inquiry and suggested that they be sacked.

“You have demonstrated that maternity safety doesn’t matter to you, but self-preservation does. Your failure to engage constructively and with candour in this review process is further proof you are unfit to keep mothers and babies safe.

“Questions need to be asked by senior leaders and regulators whether you are fit to work in the NHS,” they said in a statement.

Ockenden’s report told how Jack and Sarah Hawkins experienced “suppression of information” by NUH and several regulatory bodies when they were searching for the truth about why their daughter Harriet had died just before her birth in 2016.

Kim Thomas, the chief executive of the Birth Trauma Association, said that Ockenden’s “shocking” report had shown how “when complaints were made, the trust’s instinct was to cover up, rather than investigate, failings”.

“Sadly, we believe that Nottingham is not unique. As a charity we hear similar stories from hospitals throughout the country,” she added.

Murray announced that Martha’s rule – which gives patients the right to an independent second opinion of their care by a separate clinical team – will be implemented at every maternity unit in England, as Ockenden suggested.

In future, current or past NHS staff who refuse to give evidence to maternity inquiries will have to do so or risk being jailed for up to two years, to try to break the ingrained “culture of silence” that often accompanies care failings and medical negligence.

Ockenden is already leading Nottingham-style reviews of what families say are endemic failings of NHS maternity care in Leeds and Sussex.

In an open letter “to the people and communities of Nottinghamshire”, the NUH chief executive, Anthony May, and chair, Nick Carver, said: “We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services.”

Murray vowed that the government and NHS bosses would “deliver lasting change” to improve maternity services across England. Ockenden’s findings will help inform an action plan to overhaul childbirth services that the Department of Health and Social Care’s maternity taskforce is drawing up.