The final report of Donna Ockenden’s independent review into maternity and neonatal services at Nottingham University Hospitals NHS Trust was published today.
The review draws on the experiences of more than 2,500 families. It sets out serious failures in care. These include not listening to families, missing early signs that something was wrong, and delays in acting on concerns.
At its heart are families whose lives have been changed forever.
Familiar themes for families affected by infection
For families affected by infection, including group B Strep, these themes may feel all too familiar. Missed opportunities to recognise when something was wrong, including signs of infection. Delays in treatment. Harm that may have been preventable.
Stronger safety systems — and Martha’s Rule
The report calls for a stronger safety culture across maternity services. It highlights the need for better communication, consistent training, and clear escalation pathways.
While system pressures are real, the report also shows that basic signs of deterioration and infection are still being missed.
This includes the rollout of the rollout of Martha’s Rule which gives patients and families a way to ask for an urgent clinical review if they are worried.
Jane Plumb MBE, Chief Executive of Group B Strep Support, said:
“We welcome steps that give families a stronger voice and help ensure concerns are taken seriously. Martha’s Rule has real potential to save lives if it is consistently implemented and families feel confident using it.
But these reforms come after devastating failures. Too many families have experienced avoidable harm, often when early signs that something was wrong were missed or not acted on. Clear pathways for escalation are vital – but so is getting the basics right, including recognising and preventing infection.
We need a system that listens, acts quickly, and prevents harm in the first place. That must include stronger action on preventable infections, including group B Strep, which remains the leading cause of severe infection in newborn babies.”
What this means for Group B Strep Support
For Group B Strep Support, the report reinforces something very clear. Safe care depends on getting the basics right.
- Families need clear, evidence-based information.
- Staff need consistent training.
- Teams need to recognise risks and act quickly.
Group B Strep is a common bacterium. It can cause serious infection in newborn babies, often very rapidly after birth. Many cases are preventable. Yet access to information, testing and consistent care still varies across the UK.
Actions that can happen now
Alongside wider maternity reforms, practical steps can improve safety now:
- ensure every pregnant woman and pregnant person receives clear, evidence-based information about group B Strep
- provide consistent training for maternity and neonatal staff
- make sure national guidance is followed across all NHS Trusts
Time for real change
This report is first and foremost about families. Their experiences must now lead to real and lasting change.
That means listening, acting quickly, and preventing harm wherever possible – including tackling preventable infection.
