A landmark review into maternity services at Nottingham University Hospitals NHS Trust has found that more than five hundred mothers and babies suffered avoidable harm or death due to longstanding systemic failures. Led by senior midwife Donna Ockenden, the largest maternity investigation in NHS history examined hundreds of cases and concluded that many outcomes could potentially have been prevented through different care and management. The review identified chronic staffing shortages, inadequate training, failures to listen to parents, poor incident investigations, and a culture where concerns were often ignored. It also highlighted distressing failures in post-death care and communication with bereaved families. Ockenden said many of the problems had been known about for years but were not properly addressed by senior leaders. Families involved in the review described years of trauma, frustration, and a lack of accountability. The Government has pledged action, including stronger powers to compel participation in future investigations and expanded patient safety measures.