An independent inquiry has detailed extensive clinical and administrative failures within the maternity services of the Nottingham University Hospitals (NUH) NHS Trust, resulting in significant avoidable harm and fatalities.

一項獨立調查詳細列舉了諾丁漢大學醫院 (NUH) NHS 信託產科服務中廣泛的臨床與行政失效，導致了重大且可避免的傷害與死亡。

The investigation, conducted by senior midwife Donna Ockenden, analyzed 2,500 cases between 2012 and 2025 at the Queen’s Medical Centre and Nottingham City Hospital. The findings indicate that 520 patients—comprising 444 women and 76 neonates—experienced outcomes categorized as having 'significant' or 'major' concerns. Specifically, the review identified that 155 infants died and 105 suffered severe injuries, including permanent brain damage, which may have been mitigated through appropriate clinical management. These adverse outcomes were attributed to a confluence of factors, including the misinterpretation of fetal heart monitoring, inadequate escalation of critical cases to senior clinicians, and a failure to recognize neonatal distress during labor.

此次由資深助產士 Donna Ockenden 領導的調查，分析了 2012 年至 2025 年間在 Queen’s Medical Centre 與諾丁漢市醫院的 2,500 個個案。結果顯示，520 名患者（包括 444 名婦女與 76 名新生兒）的結果被歸類為具有「顯著」或「重大」疑慮。具體而言，審查發現 155 名嬰兒死亡且 105 名受嚴重傷害，包括永久性腦損傷，而這些情況若能通過適當的臨床管理，本可得到緩解。這些不良結果歸因於多種因素的共同作用，包括對胎兒心率監測的誤讀、危急個案未能及時呈報至資深臨床醫生，以及未能識別分娩期間的新生兒窘迫。

Institutional dysfunction was characterized by a pervasive 'toxic' workplace culture and chronic understaffing. The report documents the existence of intimidating staff cliques and the normalization of bullying, which inhibited junior personnel from challenging unsafe clinical decisions. Furthermore, the inquiry noted a persistent disregard for patient concerns; women, particularly those from marginalized ethnic backgrounds, reported being dismissed or stereotyped. This lack of responsiveness was linked to maternal deaths and severe complications. The report also highlighted profound failures in post-death care, including the inappropriate disposal of fetal remains as clinical waste.

機構功能失調的特徵在於普遍存在的「毒性」職場文化與長期的人力不足。報告記錄了職場中存在恐嚇性質的派系以及欺凌現象的常態化，這使得初級人員不敢對不安全的臨床決定提出質疑。此外，調查指出院方持續無視患者的憂慮；婦女們，尤其是來自邊緣化種族背景的人，報告稱自己被輕視或被刻板印象化。這種缺乏回應的態度與產婦死亡及嚴重併發症相關。報告還強調了死後護理的嚴重失效，包括將胎兒遺骸作為臨床廢物不恰當地處理。

Administrative negligence was evident in the trust's failure to act upon internal warnings. Evidence suggests that senior leadership was apprised of the crisis as early as 2010, yet failed to implement necessary reforms. The inquiry further noted a 'culture of organizational denial,' where the trust prioritized reputational management over patient safety. This is exemplified by the refusal of numerous former executives to engage with the review process. Consequently, the government has announced the national implementation of 'Martha’s Rule' to provide patients with independent second opinions and has proposed legislation to compel NHS staff to provide evidence in future inquiries under threat of imprisonment.

行政疏忽顯見於信託基金未能對內部警告採取行動。證據表明，高層領導早在 2010 年就已被告知危機，卻未能實施必要的改革。調查進一步指出存在一種「組織否認文化」，信託基金將名譽管理置於患者安全之上。許多前任高管拒絕參與審查程序的行為即是例證。因此，政府已宣佈在全國實施「瑪莎法則」(Martha’s Rule)，以為患者提供獨立的第二意見，並擬議立法強制 NHS 員工在未來的調查中提供證據，否則將面臨監禁威脅。

The NUH Trust has issued an unreserved apology, while the government considers a statutory public inquiry to ensure systemic accountability and the implementation of lasting safety reforms.

NUH 信託已表達毫無保留的道歉，而政府正考慮進行法定公開調查，以確保系統性問責並實施持久的安全改革。