A big report says that hospitals in Nottingham did a bad job. Many mothers and babies were hurt or died because the doctors made mistakes.

一份重大報告指出諾丁漢的醫院表現不佳。許多產婦與嬰兒因醫師失誤而受傷或死亡。

A woman named Donna Ockenden looked at 2,500 cases. She found that 520 people had big problems. 155 babies died and 105 babies got brain damage. The doctors did not watch the babies' hearts correctly.

一名叫 Donna Ockenden 的女士審查了 2,500 宗個案。她發現有 520 人出現嚴重問題。155 名嬰兒死亡，且 105 名嬰兒受到腦部損傷。醫師未能正確監控嬰兒的心跳。

The workplace was bad. Some staff were mean to other staff. This is called bullying. Doctors did not listen to the mothers. They were especially mean to women from different countries.

工作環境惡劣。部分員工對其他同事態度惡劣，這被稱為職場欺凌。醫師不聽取產婦的意見，尤其是對來自不同國家的女性更加刻薄。

The bosses knew about these problems in 2010. They did not fix them. They only wanted the hospital to look good. Now, the government has a new rule. Patients can now ask a second doctor for help.

管理層早在 2010 年就已知曉這些問題，但並未採取行動解決。他們僅僅希望醫院的形象良好。現在，政府出台了新規定，患者可以要求第二位醫師提供協助。

The hospital said sorry. The government wants to make sure this does not happen again.

醫院已表示道歉。政府希望確保此類事件不再發生。

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。

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。