A report says a hospital in Nottingham did a bad job. Many mothers and babies got sick or died.

一份報告指出諾丁漢的一家醫院表現不佳，導致許多產婦和新生兒生病或死亡。

A woman named Donna Ockenden looked at 2,500 cases. She found that 520 mothers and babies had problems. The hospital did not have enough staff. Doctors did not listen to some mothers, especially women of color and teenagers.

一名名為 Donna Ockenden 的女性審查了 2,500 宗個案。她發現 520 名產婦和新生兒出現問題。該醫院人手不足，醫生不理會部分產婦，尤其是膚色較深的人群與青少年。

The hospital also had problems with dead bodies. They did not have enough freezers. Eight bodies were in bad condition. The police arrested two people because of these problems.

該醫院在處理遺體方面也存在問題。由於冷凍櫃不足，有八具遺體狀態不佳。警方已因此逮捕兩人。

Now the government has a new rule. Patients can ask a second doctor for help. Also, hospital staff must help with reports or they can go to prison. A new group is helping the hospital fix 100 problems.

現在政府制定了新規定。病人可以要求第二位醫生提供協助。此外，醫院職員必須配合報告撰寫，否則可能面臨監禁。目前有一個新小組正協助該醫院解決 100 個問題。

The hospital is now trying to fix these big mistakes.

該醫院目前正嘗試修正這些嚴重錯誤。

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。

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。