Donna Ockenden has published her review into Nottingham University Hospitals NHS trust.
Commenting on the report, Parliamentary and Health Service Ombudsman Paula Sussex said:
“This report adds to an overwhelming body of evidence that maternity services are failing women and families in ways that are repeated and preventable.
“For years, reviews have highlighted the same issues - failures in communication, not listening, delays in diagnosis, and poor postnatal care. Yet too often these warnings and any lessons have not translated into lasting improvement, resulting in repeated harm.
“While many NHS staff work tirelessly to provide excellent care, every woman and baby deserves safe, compassionate care, every time. It is vital now that we focus on fixing the service. NHS leaders must ensure these findings lead to real, sustained action across all Trusts.
“Listening to women and families is one of the most effective ways to prevent harm and improve care. We owe it to those affected not just to recognise these failures, but to ensure they lead to meaningful and lasting change.”