Unpublished report flags maternity failings before Nottingham review

Officials at Nottingham University Hospitals had warnings in hand before Harriet Hawkins died, raising the central accountability question in the scandal: who knew what, and why did the response lag? A previously unpublished workplace review of Nottingham City Hospital maternity services, dated 30 March 2016, had already pointed to workload pressure, inappropriate behaviour and wider culture concerns days before Harriet Hawkins was stillborn, a death that later became a landmark case in the Nottingham maternity scandal.

The review was carried out by a workplace psychologist between December 2015 and March 2016 and drew on anonymous interviews with 49 members of staff, including doctors and midwives. It was triggered after letters to staff in the maternity unit and after inspectors recorded unusual scenes on the ward, including an empty energy drink can left in the middle of a clean delivery room and butter smeared around the top of a birthing pool.

The report praised the “remarkable” commitment of staff, but the picture it painted was stark. It cited feedback from Care Quality Commission inspectors and highlighted “some concerns with the culture” in the City Hospital maternity unit. One worker said: “There is immense pressure on staff - we are mildly to moderately short-staffed all the time.” Another said: “Sometimes we go home in tears. We have our private groups in Facebook. We share on here and provide help: 'Sorry you are not supported, how are you?'” A third added: “We need to close the labour suite, rather than make it an unsafe place to work.”

The review also described problems in how patients were allocated to midwives. One account said newly qualified midwives were being given “high-risk cases” while more experienced staff were left with less complex work, adding: “This happens all the time.” It also recorded “numerous reports” of some senior staff failing to support junior colleagues and, at times, belittling them.

Donna Ockenden, who is leading the Nottingham University Hospitals NHS Trust review, said: “There were many concerns that were known about when Harriet Hawkins lost her life.” She is due to publish her findings on 24 June 2026. The NHS England review began on 1 September 2022 and is due to publish its final report by 30 June 2026, covering cases dating back to 2012 and involving around 2,500 families.

The unpublished report adds to scrutiny of how quickly warning signs were acted on. Nottinghamshire Police opened a corporate manslaughter investigation in September 2023, while the UK government launched a rapid national maternity and neonatal investigation on 23 June 2025, saying the problems stretched back more than 15 years and involved recurring failures in care, safety, leadership and culture. Harriet Hawkins’s parents, Jack and Sarah Hawkins, have long said they believed no one had been held accountable for their daughter’s death, a concern that now sits at the heart of the wider national reckoning.