Royal College of Midwives documents persistent deficit
AVOIDABLE DEATHS BY INQUIRY — CUMULATIVE PATTERN
Each point represents an NHS maternity inquiry and the avoidable deaths/harms it documented. Hover for detail.
2015
Dr. Bill Kirkup
Morecambe Bay Investigation (Kirkup Report I)
Identified 'serious failures' in care involving 11 babies and 1 mother; found a 'dysfunctional' culture and failure to investigate incidents.
University Hospitals of Morecambe Bay NHS Foundation Trust
12
HARMS
2022
Donna Ockenden
Ockenden Report (Final)
Found 201 avoidable baby deaths and 9 avoidable maternal deaths (210 total) over two decades. Staff dismissed concerns, management prioritised reputation, regulatory oversight failed.
Shrewsbury and Telford Hospital NHS Trust
210
HARMS
2022
Dr. Bill Kirkup
Kirkup Report II — East Kent
Found 45 babies might have survived with better care, plus maternal deaths. Described a culture where staff felt unable to raise concerns.
East Kent Hospitals University NHS Foundation Trust
45
HARMS
2026
Donna Ockenden
2026 Trust Inquiry (June)
More than 500 mothers and babies died or suffered potentially avoidable harm. Inquiry described 'deeply embedded systemic failures' within a 'toxic' institutional culture.