NHS maternity report warned of Nottingham failures years before inquiry

An NHS maternity report that was never made public raised serious concerns about care standards at Nottingham’s maternity units well before a sweeping national inquiry was launched, it has emerged. The document, seen by this publication, identified staffing shortfalls, communication breakdowns and inadequate risk assessments as far back as several years before the formal review began.

What the hidden report found

The unpublished assessment, compiled by a regional NHS oversight body, flagged at least 14 specific areas of concern across two Nottingham hospital sites. It described repeated failures to escalate high-risk cases, a shortage of experienced midwives during night shifts, and what it called a “culture of reluctance” when it came to raising safety concerns internally. Yet none of the findings triggered a formal, public response from trust leadership at the time. The report was filed, and largely forgotten.

That silence now looks deeply significant.

Timeline raises uncomfortable questions

The Nottingham maternity inquiry, one of the largest of its kind in NHS history, is already examining hundreds of cases involving baby deaths and serious injuries going back to 2010. Families involved in that process say they weren’t told about this earlier internal document — and many are angry. So the revelation that warning signs were documented and not acted upon adds a painful new dimension to an already devastating story.

A spokesperson for the NHS trust said: “We take all concerns about maternity safety extremely seriously and are fully committed to cooperating with the ongoing inquiry. We will review any previously compiled assessments as part of that process.”

But critics say that kind of language doesn’t cut it anymore. Campaign groups representing affected families have called for full disclosure of all internal reports, regardless of when they were written or who commissioned them.

Pattern of ignored warnings

What makes this particular document troubling isn’t just its content — it’s the timing. It was completed approximately three years before the trust was formally placed under scrutiny. During that window, babies died. Mothers were harmed. And the problems described in the report didn’t go away; by most accounts, they got worse.

Maternity safety experts say Nottingham isn’t unique in this respect. Internal NHS reports are routinely produced, shared within a closed circle of managers, and then shelved when they prove inconvenient. There’s no consistent requirement for trusts to publish such documents or act on them within a defined timeframe. That’s a systemic gap that campaigners have been pushing to close for years.

What happens next

The inquiry team, led by senior clinician Donna Ockenden — who previously led a similar review in Shrewsbury — is expected to request all internal documentation from the trust. Her team will likely be asking why this report wasn’t part of the materials originally handed over.

For families still waiting for answers, the disclosure brings little comfort. But it may, at last, force a reckoning with just how long these problems were known about — and by whom.