What Do the Ockenden Reports Mean for Midwife and Obstetrician Expert Witnesses?

Summary

• Donna Ockenden’s Nottingham report was published on 24^th June 2026 and reviewed around 2,500 family cases.
• Different care may have changed the outcome for 260 babies, including 155 deaths and 105 cases of serious injury.
• The earlier Shrewsbury and Telford report reviewed 1,486 families and found that as many as 200 babies may have died.
• Together, the two reports form the largest body of maternity safety findings in NHS history.
• Expert evidence is central to maternity negligence claims, so solicitors must instruct midwifery and obstetric experts whose current clinical practice matches the issues in dispute and who understand Bolam, Bolitho and CPR Part 35.

Donna Ockenden, Chair of the Independent Maternity Review, published her final report into maternity and neonatal services at Nottingham University Hospitals NHS Trust on 24^th June 2026. The review covered around 2,500 family cases and found that different care may have altered the outcome for 260 babies, including 155 deaths and 105 cases of serious injury. The Nottingham report follows the 2022 final report into Shrewsbury and Telford Hospital NHS Trust, which reviewed 1,486 families and found that as many as 200 babies may have died. The two investigations represent the largest body of maternity safety findings in the history of the NHS.

What clinical failures do the Ockenden reports identify most often?

• The Nottingham report identifies recurring failures across the intrapartum period that the Review Team describes as “suboptimal care in intrapartum fetal monitoring, assessment and management of the latent phase of labour, and the identification, recognition, and management of post-partum haemorrhage”.
• In relation to CTG interpretation specifically, the report records “examples of incorrect interpretation, inappropriate use of oxytocin, poor documentation, failure to use fetal scalp electrodes when indicated; lack of coordinator oversight, poor escalation and poor training”.
• Beyond the labour ward, antenatal care across the review period was characterised by what the report calls “variation in risk assessment, surveillance, documentation, communication and escalation, contributing to missed opportunities for earlier intervention and avoidable harm”.
• A separate and persistent failure concerned triage: the Review found “many examples of poor telephone risk assessments and/or missing documentation” and a culture of discouraging women from attending in person.
• On staffing and culture, the report states that “a bullying and toxic culture has been a long-running theme in NUH’s maternity services” with more than 40% of staff reporting that they had either witnessed or personally experienced bullying as a regular part of their working environment.
• Only 11% of staff reported sufficient staffing for the workload.
• The report identifies a further “running theme of poor governance within maternity going back to 2012, including Serious Incidents not being investigated and reported in a timely manner and failure to learn and change after incidents”.

What do solicitors need from a midwife or obstetrician expert witness?

The clinical failures identified in both Ockenden reports are precisely the questions that midwife and obstetrician expert witnesses are asked to address in litigation arising from these trusts and from NHS maternity care more broadly in England and Wales. The reports establish the evidential context in which claims are assessed, define what the standard of care required, and in some instances demonstrate that particular practices lacked clinical justification. That has direct consequences for the weight courts will attach to expert opinions that endorse those practices.

A midwifery expert may be asked whether the CTG trace was correctly interpreted, whether triage risk assessment met the applicable standard, and whether escalation was timely. An obstetrician expert may be asked whether, once escalated, the medical response including the decision on mode of delivery was appropriate. Where a case involves risk assessment during the antenatal period, an obstetrician expert addresses whether the relevant surveillance and documentation met the standard applicable at the time of those events.

A midwife or obstetrician expert witness in a maternity negligence claim in England and Wales must hold current professional registration, have active clinical experience in the specific sub-discipline required, and address the applicable standard of care with precision. Identifying the right expert before instruction is the most important step in the process.

Final words

For solicitors representing clients in such sensitive cases, it is imperative to choose an expert whose current clinical practice matches the narrow forensic question in issue and to give them complete, indexed records from the outset. For experts, it means understanding how the Ockenden findings sit alongside Bolam, Bolitho and CPR Part 35, recognising the implications those reports have for what counts as justified practice, and stating opinions clearly, independently and within their true scope of expertise.

Frequently asked questions

Do the Ockenden findings create liability in individual negligence claims?

No, the Ockenden findings do not create liability in individual claims. The reports identify systemic and cultural failures at the trusts reviewed. Liability in any individual clinical negligence claim in England and Wales requires an independent expert analysis of whether the specific care fell below the applicable standard at the time, and whether that failing caused the injury complained of. The Ockenden findings provide evidential context but do not determine the outcome of any individual case.

What is the standard of care test in a maternity negligence claim?

The standard of care test in a maternity negligence claim is the same as in any clinical negligence claim: the court asks whether the care fell below the standard of a reasonably competent practitioner in the relevant field, applying the Bolam and Bolitho principles.

In practice, that means asking whether a responsible body of obstetric or midwifery opinion would regard the care as acceptable, and then whether that body of opinion can be defended as logical. Expert witnesses in maternity cases must apply that test to the specific facts: the timing of assessments and interventions, CTG interpretation and escalation, consent discussions, and adherence to applicable guidance at the time of the events.

How many expert witnesses are typically needed in a birth injury claim?

Most birth injury claims in England and Wales require both a midwifery expert and an obstetric expert, whose scopes are determined by the specific facts. In claims involving the condition and treatment of the baby after delivery, a neonatologist is also required. In claims involving consent to a particular mode of delivery, the obstetric expert addresses what information should have been provided and whether any omission was causative of the harm suffered.

Last reviewed: July 2026