Mothers and newborns across the country will be better protected, as landmark patient safety measure Martha’s Rule will be rolled out to all maternity settings in England, following a string of serious and sustained failures at maternity wards in the Nottingham University Hospitals NHS Trust (NUH).
Donna Ockenden’s review – the largest into maternity and neonatal services in NHS history – considered the experiences of maternity care for 2,500 families and found women ignored or complaints dismissed, missed opportunities to identify deteriorating patients and a culture of silencing both junior staff and parents.
The government will today (Wednesday 24 June) commit to rolling out Martha’s Rule across maternity and neonatal wards in England to ensure every parent can request a rapid review from an independent medical team if a baby or mother’s condition is deteriorating and they are concerned this is not being responded to.
The scheme – which is helping transform the NHS’s culture and has been rolled out for inpatients in every acute hospital in England – has already been piloted in 15 maternity and neonatal settings, with rollout to more expected this year.
NHS data shows that there have already been over 2,100 calls to Martha’s Rule requiring changes in a patient’s treatment, with over 600 calls leading to potentially life-saving interventions to transfer them to enhanced levels of care.
The safety initiative is named after Martha Mills, who died in 2021 aged 13 after developing sepsis in hospital, where she had been admitted with a pancreatic injury after falling off her bike.
Martha’s family’s concerns about her deteriorating condition were not responded to, and in 2022 a coroner ruled that Martha would probably have survived had she been moved to intensive care earlier.
Secretary of State for Health and Social Care James Murray said
Last week I met with the families in Nottingham and heard first-hand about the devastating loss they have suffered, often caused by horrendous care they received on the NHS. Donna Ockenden’s review lays bare a culture where too many voices went unheard, too many opportunities to prevent harm were missed and too many lives were lost. That’s why we have to take action, and quickly.
No family should ever have to battle the system that is meant to care and protect them. That is why Martha’s Rule is so fundamental. It provides a way for a concerned mum or family member to raise the alarm before it is too late.
I want families across the country to feel safe when they walk through the doors of their maternity settings. Today marks a step in achieving that – but this is just the beginning.
I want to thank Donna for her work over the last 4 years. These clear recommendations will form part of our national plan to deliver real improvements in maternal and neonatal care, in Nottingham and beyond.
Those responsible for failures will be compelled to give evidence to investigations into failing maternity care to end a culture of secrecy and prevent further harm.
This action will help ensure the reviews in Leeds and Sussex are fair and comprehensive, so that uncovering the truth does not rely solely on those who choose to come forward voluntarily. Those who refuse to do so or deliberately withhold information about failures could face up to 2 years in prison.
The measures are designed to tackle the culture of silence exposed by the Nottingham review, where over 800 staff gave evidence but many described a culture of being silenced by senior clinicians and hospital bosses when raising concerns around patient safety. This will ensure that for both reviews of Sussex and Leeds, staff are heard and families are closer to getting the answers they deserve.
Reports of incidents in mortuaries across the country will also be more tightly reviewed, following the deeply concerning findings about the lack of respect given to deceased babies, and the complete disregard to their dignity. The Human Tissue Authority will require all mortuaries to review internal records dating from 2015 to 2026 to ensure all incidents have been logged and reported. This will strengthen accountability, ensuring concerns cannot be hidden or overlooked.
Donna Ockenden, Chair of the Independent Review, said
To every family who came forward, I want to say this we have listened. It is my sincere hope that through this review you now feel as though your voices have been heard and what happened to you and your families has been recognised and will be acted upon.
Today, we have started the process of providing answers. We have set out clear findings and essential actions to address the concerns raised by families and staff. These actions when implemented will drive improvement both within perinatal services at Nottingham University Hospitals NHS Trust and across England.
While the majority of births on the NHS are safe, too many families have suffered harm that should never have happened. Their experiences will drive real and lasting change to maternity services in England, driven by staff working to improve services.
Michelle Welsh MP, the government’s first Maternity Adviser, said
Donna Ockenden’s review is a stark reminder of the devastating consequences when women, families and frontline staff are not listened to. The experiences of the Nottingham families must be a catalyst for lasting change across maternity and neonatal services.
We owe it to every mother, baby and family affected by these failures to ensure that lessons are learned and that meaningful improvements are delivered across the NHS.
The measures announced today – including the extension of Martha’s Rule and the Hillsborough Law – are a positive step in ensuring the lived experience of women is at the heart of reforming maternity care.
NUH is also taking immediate action, introducing a new helpline for concerned members of the public available from today. The helpline will provide support for families who use or have used NUH maternity and neonatal services and may have concerns or questions following the publication of the report and media coverage. Details on how to access this service will be available via the NUH website.
Kate Brintworth, Chief Midwifery Officer for England, said
I am so sorry for the heartbreaking loss, grief and pain experienced by women and families at Nottingham.
My thoughts are with those who have been harmed, bereaved or let down by the care they received. They have shown extraordinary courage in speaking up, and their voices must be at the centre of how the NHS responds.
We’ve introduced new national clinical standards which are helping prevent harm and ensure women get urgent maternity care more quickly, and local leaders and staff in Nottingham are working hard to address these failings. However, this report shows the scale of what still needs to change.
I know it can be worrying for women using maternity services, but please continue to speak to your midwife or maternity team if you have any concerns.
This government has already taken urgent action on maternity. Since 2025, the government has invested £145 million to improve the safety of maternity and neonatal care facilities. Other measures include
- implementing a new programme to reduce the 2 leading causes of avoidable brain injury during labour
- delivering a package of initiatives and interventions to reduce stillbirths, neonatal brain injury, neonatal death and preterm birth
- introducing a Perinatal Culture and Leadership Programme to develop a culture of safety, learning and support for leads from all maternity and neonatal units
- expanding maternal mental health services to help women and extended the baby loss certificate scheme to include all historic losses
- rolling out guidance across the NHS to tackle the leading causes of maternal death including thrombosis, mental health, epilepsy and haemorrhage
A national action plan will be developed through the National Maternity and Neonatal Taskforce, chaired by the Secretary of State, bringing together the findings of this review and Baroness Amos’ report to drive real and lasting change for women and families across the country.