An independent review has found widespread systemic failures in maternity and newborn care at the Nottingham University Hospitals (NUH) NHS Trust, which led to serious injuries and deaths.

一項獨立審查發現，諾丁漢大學醫院 (NUH) NHS 信託在產科與新生兒護理方面存在廣泛的系統性失效，導致嚴重傷害與死亡。

The review, led by senior midwife Donna Ockenden, examined 2,500 cases between 2012 and 2025. The report emphasized that 520 mothers and babies suffered avoidable harm or death, including 155 baby deaths and 105 cases of severe brain injury. These problems were caused by a combination of factors, such as a constant lack of staff, poor monitoring of fetuses, and a failure to report critical symptoms to senior doctors. Furthermore, the report described a 'toxic' workplace culture involving racism and sexism, noting that teenage mothers and women of color were often ignored by medical staff.

此次審查由高級助產師 Donna Ockenden 領導，研究了 2012 年至 2025 年間的 2,500 個案例。報告強調，有 520 名母親與嬰兒遭受了可避免的傷害或死亡，其中包括 155 宗嬰兒死亡及 105 宗嚴重腦損傷案例。這些問題是由多項因素共同造成，例如長期人力不足、胎兒監控不力，以及未能將關鍵症狀報告給高階醫生。此外，報告將職場文化描述為「有毒」，涉及種族歧視與性別歧視，並指出青少年母親與有色人種女性經常被醫療人員忽視。

Negligence also occurred in the care of deceased patients. Inspections by the Human Tissue Authority (HTA) discovered that eight bodies had decayed significantly because there was not enough freezer space. Other serious errors included the wrong disposal of a fetus and failures to verify identities when moving remains. Consequently, the Nottinghamshire Police started 'Operation Perth,' which led to the arrest of two people on suspicion of misconduct in a public office.

在處理已故病患方面同樣存在疏忽。人體組織管理局 (HTA) 的檢查發現，由於冷凍空間不足，導致八具遺體嚴重腐爛。其他嚴重錯誤包括錯誤處理胎兒，以及在搬運遺體時未能核對身份。因此，諾丁漢郡警方啟動了「珀斯行動」(Operation Perth)，導致兩人因涉嫌在公職上失職而被逮捕。

In response, the government has extended 'Martha’s Rule' to all maternity units, which gives patients the right to a second opinion. To ensure staff cooperate with future reviews, the government stated that NHS employees who refuse to help may face up to two years in prison. At the trust level, a Learning and Improvement Board has been created to manage about 100 required changes. However, affected families are still calling for a formal public inquiry to ensure full accountability.

作為回應，政府已將「瑪莎法則」(Martha’s Rule) 擴展至所有產科單位，賦予患者尋求第二意見的權利。為確保員工配合未來的審查，政府表示拒絕協助的 NHS 員工可能面臨最高兩年的監禁。在信託層面，已成立一個學習與改善委員會來管理約 100 項必要的變革。然而，受影響的家庭仍要求進行正式的公開調查，以確保全面問責。

The NUH NHS Trust is now following a recovery plan under independent supervision after the discovery of these deep clinical and administrative failures.

在發現這些深層次的臨床與行政失效後，NUH NHS 信託目前在獨立監督下執行恢復計劃。