The Ockenden report on Nottingham maternity services - next steps for chief people officers

As chief people officers (CPOs), our role in briefing the board on the Nottingham Ockenden report is a critical responsibility. This is not simply a clinical or regulatory issue that we can leave to other colleagues. It is a fundamental people, culture, leadership, and governance issue that demands board-level ownership. 

We sit at the heart of our organisational culture. 

We must reflect on how we improve, and alongside fellow board members, demonstrate leadership in ensuring our organisations are open to learning. We also have a key role in reassuring patients and staff that we are moving quickly to build on the safe and compassionate cultures we are so determined to achieve.

The final Ockenden report into maternity services at Nottingham University Hospitals NHS Trust (NUH), published on 24 June 2026, demands our urgent attention. The largest maternity inquiry in NHS history, it reviewed over 2,500 family cases from 2012–2025. It identified 162 potentially avoidable deaths (156 babies and six mothers) and over 500 instances of potentially avoidable harm. 

The findings point to systemic failures: chronic under-staffing, poor monitoring, delays in care, dismissive attitudes toward women’s concerns, and a toxic culture. It really is a tough read and devastating for the families involved.

The report paints a deeply troubling picture: 

• insufficient staffing that prevented basic training and safe care delivery
• a failure to listen to families, particularly those from minority ethnic backgrounds facing racism and dismissed symptoms
• bullying and hierarchical behaviours that silenced staff voices
• leadership and governance weaknesses that allowed problems to persist for over a decade.

Families described cruel treatment, lack of compassion, and disempowerment at a time of profound vulnerability. Staff reported bullying, unapproachable managers, and ignored concerns about workload and safety. 

While some improvements have been noted since 2021 – including new staffing investments and cultural initiatives – sustained change is still required. Recent inspections acknowledge progress but highlight ongoing risks. 

For CPOs, this is not just a clinical story. 

It is a people story about how culture, leadership behaviours, workforce planning and psychological safety directly impact patient outcomes and staff wellbeing. 

I know there will be recommendations and guidance coming for boards but in the meantime, here are my suggestions on what CPOs could be doing now:

1. Approve appropriate board-led culture and leadership diagnostics in high-risk clinical areas (they will probably already be on your and other colleagues’ radars) with results reported back to the board. Use anonymous pulse surveys, focus groups, and Freedom to Speak Up data to identify issues such as bullying, hierarchy and psychological safety gaps. Act on findings visibly and quickly.
2. Strengthen oversight of safe staffing. These discussions often sit across people and quality committees. Work with clinical leads to ensure workforce models reflect acuity, training needs, and escalation plans when staffing levels fall short.
3. Review leadership development for compassion and inclusion. Ensure programmes reach the right leaders at the right level and focus on listening, inclusive decision-making, and tackling bias and racism. Link progression and performance clearly to these behaviours, with visible board participation. 
4. Further embed patient and staff voice mechanisms. Receive regular themed reports on concerns, especially from diverse groups, ensuring rapid escalation routes and genuine co-production. Track how concerns are handled with curiosity and rigour, with zero tolerance for discrimination. I would also recommend using evidence and resources from the NHS Race & Health Observatory (RHO), designed to help organisations, teams and individuals improve maternal health outcomes.
5. Review talent and succession processes. Scrutinise recruitment, promotion, and performance management for evidence of bias, cliques or lack of transparency. Build diverse leadership pipelines that reflect the communities we serve.
6. Invest in psychological support. Ensure rapid access to trauma-informed support for staff involved in serious incidents, alongside support for families. Ensure regular reports on take up and efficacy of the support. My sense is we have been too passive in this area. Prioritise retention of experienced midwives and obstetric staff.
7. Integrate people metrics into quality and safety reporting. Work with executive colleagues to create clear metrics linking people KPIs (staff survey scores, turnover in critical areas, speaking-up trends) to quality and safety outcomes. Hold leaders accountable through appraisals and exit processes.
8.  Lead system-wide learning. Share lessons internally and across systems. Work with HR peers to standardise training, escalation, and culture interventions. Position people teams as the bridge between clinical governance and organisational development.

Safe, compassionate care starts with how we lead and support our people.

We have a responsibility to drive the cultural and workforce changes needed so that every family and every member of staff experiences the standard of care we would expect for our own loved ones. 

This work is hard, but it goes to the heart of our role.