Hundreds of Nottingham babies and mothers die after ‘systematic’ collapse.

2,500 families and more than 800 staff members contributed to the review, which began in 2022.

But Ockenden said there were “gaps” in knowledge, as some senior executives refused to participate in her review.

The report said that 66 former and current senior colleagues were approached by the CEO of the Trust, 37 of them were approached and 35 of them were interviewed.

However, experts in the review concluded that there were “preventable” outcomes in 444 maternal cases and 76 neonatal cases through May 2025.

All of these 520 cases were graded two or three for harm, with grade three indicating “significant concerns” and grade three “major issues” in care.

The second class represents suboptimal care, in which different leaders make a difference to outcomes, and the third class represents different leaders who are expected to make a difference in causality.

As some leaders refused to participate in the review, the government announced that the MARTA regime would be extended to increase accountability and safety for mothers and infants.

Other measures include forcing NHS staff – past and present – to provide evidence of their refusal to take part in future maternity assessments. or face up to two years in prison.even if It is not yet clear How to implement this.