The three-year report, which outlines essential actions for NUH and national maternity services, was the based on the experiences of over 2,500 families across a decade who experienced serious failings, including avoidable deaths, stillbirths, neonatal deaths and life-changing injuries to both babies and mothers.

Ockenden said: ‘The evidence heard by the Review Team makes clear that we are not yet consistently providing safe, equitable and compassionate care to all women, babies and families. That must change.'

The review chair said NUH faced ‘a significant journey of improvement ahead' while acknowledging progress had begun and ‘important foundations have been laid'.

In a review first, Ockenden and her team will continue to oversee the trust's improvement programme over the next two years.

As well as local actions for NUH, the report sets out national Immediate and Essential Actions (IEA) to improve maternity care across England.

The actions cover: listening to women and families; developing a nationally agreed perinatal workforce planning tool; mandatory training; improvements to early identification of risk; incident investigation and family involvement; commitment to increasing accountability and learning systems; creating compassionate, inclusive and psychologically safe working environments; and improvements in the standard of care following death.

Secretary of state for health and social care James Murray said: ‘We will reflect on these findings and lessons from Nottingham will form part of our national plan to deliver real improvements in maternal and neonatal care for all families.'

In an open letter, chair and chief executive Nick Carver and Anthony May said NUH had failed the women and families it served.

The letter stated: ‘We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services.  

‘We failed you, and on behalf of Nottingham University Hospitals Trust, we accept responsibility for our failings.  

The leaders said ‘important changes have been made and we believe our services are now safer, kinder and better led'.

‘We recognise that trust is earned through actions, not words,' they added. ‘We know, also, that families and the wider public will judge us not by what we say today, but by what we do next.'

Reaction 

Interim acute and ambulance network director at The NHS Alliance, Matthew Hopkins, said: ‘The extended roll out of Martha's Rule to all maternity services is a positive step. We have already seen significant safety benefits since this approach was introduced in the NHS and its wider implementation will provide reassurance for many more patients, carers and families.

 

‘The decision to compel staff who are responsible for maternity care failures to give evidence to investigations should improve transparency and accountability, and help establish key lessons in a timely way.'

The King's Fund chief executive, Sarah Woolnough, said: 'So many of the horrific care scandals in the NHS have their roots in some people closing their ears and eyes to what is right in front of them. Services in the NHS are under pressure and people are stretched, but listening to a patient or carer is not a "nice to have" – it is core part of delivering safe and effective care and treating people with the dignity and respect they deserve. If implemented well, extending Martha's Rule could play a vital role in making maternity services safer for mothers and their children, and turning the NHS into more of the listening and learning organisation we want it to be.'

Angela McConville, chief executive at NCT, said: ‘We welcome both the extension of Martha's Rule and stronger powers to compel NHS staff to give evidence to future maternity reviews. The recommendations in this report must now be acted on and lead to real change.  

 

‘Women and parents should never have to fight to be heard when they are worried about their own or their baby's safety. It is now up to leaders across Government and the NHS to show the conviction and compassionate leadership needed to drive lasting change, backed by sustained long-term investment. Trust will only be rebuilt if there is accountability at every level. The time for action is now.'

Chris Graham, group chief executive at Picker, said: ‘While it is positive that families were closely involved in the Ockenden inquiry at Nottingham, we cannot underestimate the emotional toll sharing these experiences will have taken on patients and their families. We owe it to them to act on these findings - and to make the involvement of patients and families a routine feature of maternity and neonatal services. Only by listening to and acting on what patients tell us about their needs and their experience of care can we deliver a truly person centred NHS.'