An independent investigation has revealed widespread clinical and administrative failures within the maternity services of the Nottingham University Hospitals (NUH) NHS Trust. These failures led to significant avoidable harm and several deaths.

一項獨立調查揭露了諾丁漢大學醫院 (NUH) NHS 信託基金會產科服務中普遍存在的臨床與行政失誤。這些失誤導致了重大且可避免的傷害以及多起死亡事件。

The investigation, led by senior midwife Donna Ockenden, examined 2,500 cases between 2012 and 2025. The findings show that 520 patients—including 444 women and 76 newborns—suffered serious harm. Specifically, 155 babies died and 105 suffered severe injuries, such as permanent brain damage, which could have been prevented with better medical care. The report emphasized that these outcomes were caused by several factors, such as misreading heart monitors and failing to alert senior doctors when cases became critical.

由資深助產師 Donna Ockenden 領導的調查，審查了 2012 年至 2025 年間的 2,500 個個案。調查結果顯示 520 名患者（包括 444 名女性和 76 名新生兒）遭受了嚴重傷害。具體而言，有 155 名嬰兒死亡，105 名嬰兒遭受嚴重傷害（如永久性腦損傷），而這些傷害若有更好的醫療護理本可避免。報告強調，這些結果是由多項因素造成，例如誤讀心率監測器，以及在個案進入危急狀態時未能通知資深醫生。

Furthermore, the report described a 'toxic' workplace culture and a constant lack of staff. It noted that bullying was common, which stopped junior staff from questioning unsafe decisions. Additionally, the inquiry found that staff often ignored the concerns of patients, especially women from ethnic minority backgrounds. This lack of attention contributed to maternal deaths and severe complications. The report also highlighted shocking failures in how the trust handled the remains of deceased fetuses, treating them as clinical waste.

此外，報告將職場文化描述為「有毒」，且長期缺乏人手。報告指出，職場欺凌現象普遍，導致初級員工不敢質疑不安全的決定。此外，調查發現員工經常忽略患者的顧慮，尤其是少數族裔背景的女性。這種缺乏關注的情況導致了產婦死亡及嚴重併發症。報告還強調，信託基金會處理死胎遺骸的方式令人震驚，竟然將其視為臨床廢棄物處理。

Finally, the investigation revealed that senior leaders knew about these problems as early as 2010 but failed to make necessary changes. The report asserted that the trust cared more about its reputation than patient safety. Consequently, the government has introduced 'Martha’s Rule' to give patients a second opinion and is proposing new laws to force NHS staff to provide evidence during future investigations.

最後，調查揭露高級領導層早在 2010 年就已知曉這些問題，但未能做出必要的改變。報告斷言，信託基金會更在意其名聲而非患者安全。因此，政府引入了「瑪莎規則」(Martha’s Rule) 以讓患者獲得第二意見，並提議制定新法，強制 NHS 員工在未來的調查中提供證據。

The NUH Trust has offered a full apology, and the government is now considering a formal public inquiry to ensure leaders are held accountable and safety reforms are permanently implemented.

NUH 信託基金會已表達全力道歉，而政府目前正考慮進行正式的公眾調查，以確保領導層被追究責任，並永久實施安全改革。