An independent review has identified extensive systemic failures in maternity and neonatal care at the Nottingham University Hospitals (NUH) NHS Trust, resulting in significant morbidity and mortality.

一項獨立審查發現，諾丁漢大學醫院 (NUH) NHS 信託基金會在產科與新生兒護理方面存在廣泛的系統性失效，導致嚴重的發病率與死亡率。

The independent review, conducted by senior midwife Donna Ockenden, analyzed 2,500 cases between 2012 and 2025. The findings indicate that 520 mothers and infants suffered avoidable harm or death, including 155 neonatal fatalities and 105 cases of serious brain injury. These outcomes are attributed to a confluence of factors: chronic understaffing, inadequate fetal monitoring, and a failure to escalate critical symptoms to senior clinicians. Furthermore, the report identifies a 'toxic' organizational culture characterized by medical misogyny and systemic racism, noting that women of color and teenage mothers were disproportionately dismissed by medical staff.

由資深助產士 Donna Ockenden 進行的獨立審查，分析了 2012 年至 2025 年間的 2,500 宗個案。調查結果顯示，有 520 位母親與嬰兒遭受了可避免的傷害或死亡，其中包括 155 宗新生兒死亡以及 105 宗嚴重腦損傷個案。這些結果歸因於多項因素的共同影響：長期人手不足、胎兒監測不足，以及未能將關鍵症狀上報給資深臨床醫生。此外，報告指出組織文化「有毒」，具有醫療歧視女性與系統性種族主義的特徵，並指出有色人種女性與青少年母親被醫護人員忽視的比例較高。

Institutional negligence extended to post-mortem care. Inspections by the Human Tissue Authority (HTA) revealed that eight bodies had reached a state of advanced deterioration due to insufficient freezer capacity. Additional breaches included the improper disposal of a fetus as clinical waste and failures in identity verification during the transfer of remains. Consequently, Nottinghamshire Police initiated 'Operation Perth,' resulting in the arrest of two individuals on suspicion of misconduct in a public office.

機構疏忽甚至延伸至死後護理。人體組織管理局 (HTA) 的檢查顯示，由於冷凍庫容量不足，導致八具遺體處於嚴重腐敗狀態。其他違規行為包括將胎兒作為臨床廢棄物不當處置，以及在轉移遺體過程中身份驗證失效。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中失職而被捕。

In response to these revelations, the government has announced the extension of 'Martha’s Rule' to all maternity units, granting patients the right to a second opinion. To ensure future compliance, the administration has stipulated that NHS personnel who refuse to cooperate with official reviews may face custodial sentences of up to two years. At the trust level, a Learning and Improvement Board has been established, chaired by MP Michelle Welsh, to oversee the implementation of approximately 100 required action points. Despite these measures, affected families continue to advocate for a statutory public inquiry to ensure comprehensive accountability.

針對這些揭露，政府已宣布將「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。為確保未來的合規性，政府規定，拒絕配合官方審查的 NHS 人員可能面臨最高兩年的監禁。在信託基金會層級，由國會議員 Michelle Welsh 主持的「學習與改進委員會」已經成立，負責監督約 100 項必要行動要點的執行。儘管採取了這些措施，受影響的家庭仍繼續倡議進行法定公眾調查，以確保全面的問責制。

The NUH NHS Trust is currently implementing a remedial action plan under independent oversight following the disclosure of profound clinical and administrative failures.

在披露深層的臨床與行政失效後，NUH NHS 信託基金會目前正在獨立監督下執行補救行動計劃。