Picture the scene. A child dies on a climbing frame at school. The headmaster calls their parent, apologising for what they say was a tragic, isolated incident. The school remains open, and everyone carries on as before. It’s unimaginable isn’t it? The school would be closed, the police called, the teachers in charge facing disciplinary action.
Yet this is how Nottingham University Hospitals NHS Trust (NUH) behaved after our baby daughter Harriet died at Nottingham City Hospital on April 17 2016, following entirely avoidable mistakes by its medical staff. Any other setting in which a child lost their life when they should have been safe would, surely, have become a crime scene.
Yet ten years on, not a single person has been held accountable for what happened to Harriet. No jobs have been lost. No jail sentences given.
Even worse, of course, we are far from alone.
On Wednesday, senior midwife Donna Ockenden’s 343-page review of Nottingham University Hospitals NHS Trust (NUH), in charge of Nottingham City Hospital and the adjacent Queen’s Medical Centre, found over 500 babies and mothers died or suffered serious harm caused by its failures between 2012 and 2025.
In the largest maternity care scandal in NHS history, babies were found to have died from conditions such as oxygen starvation and mismanaged labour, while pregnant and post-partum women were treated ‘cruelly’ and with ‘brutality’.
Shockingly, Ockenden revealed nearly half of NUH’s senior leadership team refused to talk to her as part of her inquiries. Obviously, they care more about their reputation than the state of maternity care. Which is precisely why we have become campaigners. None of the regulatory bodies responsible – the GMC (General Medical Council), NMC (Nursing and Midwifery Council), the CQC (Care Quality Commission) – are doing the work, so it is left to victims and their families.
Sarah and Jack Hawkins have spoken about their horror that baby Harriet’s death didn’t ‘lead to change’
Sarah and Jack pictured holding their daughter Harriet just after she was born
Sarah pictured clearing out the nursery after her daughter Harriet’s death
Anger is energising, but the last decade has taken its toll. We’ve both lost our jobs – ironically, working for the NHS, Jack as a consultant and Sarah a physiotherapist. For a while, we lost each other, our grief so strong we separated for four years in 2019. Our daughter Lottie, six, has grown up without her older sister.
We’re horrified that Harriet’s death didn’t lead to change and that other babies and mums died and were harmed. If we were confident the people who should be changing the systems were doing their jobs, we would stop campaigning. But we’re still not there by any stretch.
As previous maternity scandals in Shropshire and Kent have shown, these failings are not unique to NUH but systemic, happening in maternity wards across England. Statistically, there will be three avoidable baby deaths on maternity wards today alone.
This week, after Ockenden listed 18 ‘immediate and essential’ actions that needed to be taken in her report, from listening to women and families to offering better support for bereaved families, Health Secretary James Murray said he would spend six months working on an ‘action plan’. These two words should strike fear into any expectant family. There is no reason why he couldn’t instruct NHS maternity departments to implement the actions immediately. This should be a matter of the utmost urgency. Why on earth is it not?
The government also said it would introduce Martha’s rule – named after Martha Mills, who died of sepsis in 2021 following NHS failures – to all maternity units in England. The rule entitles parents to formal access to a second medical opinion, and we deeply admire what Martha’s family has achieved.
Sarah said she was ‘failed’ by the hospital after going into labour. Pictured when she was around 35 weeks pregnant
Ockenden’s report found families who did complain to the NUH about care they received were met with an ‘intimidating, male-dominated panel’ that was ‘dismissive of non-medical voices’.
While misogyny is undoubtedly to blame, so too are the many female midwives and doctors at NUH who seem to hate pregnant women just as much. Whether this disdain comes from the top, or elsewhere, we don’t know, which is one of many reasons we now need a public inquiry that would compel senior NHS staff to give evidence under oath, and answer three key questions: What happened? Why did it happen? And what do we need to do to stop this happening again?
We need to be in a courtroom deciding if it is okay for these people to be involved in the avoidable death of a completely normal baby. And those found to be responsible should be in prison.
Hospital staff knew a baby had died unnecessarily – and that other babies would die, and yet they carried on. How could that be right?
Criminal investigations are ongoing – Nottinghamshire Police have opened a corporate manslaughter investigation into NUH, to examine if the trust was grossly negligent in its management of maternity services.
But the threshold for criminal charges is high, and coroners still can’t investigate stillbirths. Proposals for a change to the law on this have been stuck in parliament since 2019. Had Harriet taken a single breath before she died, her death could have been investigated as a crime. As it was, by the time she was delivered, she was gone.
Sarah had a straightforward pregnancy. Yet when labour began, she was horribly failed. Ten times she called Queen’s Medical Centre and each time she was told not to come in. By the time staff reluctantly admitted her, crying and distressed, to Nottingham City Hospital (Queen’s Medical Centre was understaffed) the membrane surrounding Harriet was bulging out of her.
We should have been met as an obstetric emergency. Instead we were taken to a birthing suite and given a junior midwife. A doctor couldn’t find Harriet’s heartbeat because Harriet’s bladder was full. A midwife questioned why Sarah, as a physiotherapist, hadn’t told them she wasn’t urinating. It felt like she was being blamed.
With hindsight, we suspect Harriet was already dead or dying by this point. But when a doctor told us she had gone, our world fell apart. As Sarah then spent nine hours delivering Harriet – more than double the amount of time the NHS guidance says a woman should spend in the latter stage of labour – we thought she might die too. She wanted to.
Harriet, 6lbs 12oz, looked perfect as we held her afterwards, so completely normal that there was no sense to what had happened. We would have given anything for her to be alive, to be able to pour our hearts into hers.
Three months later the hospital’s internal review found Harriet’s death had been caused by an infection, that the hospital was not at fault. It was very sad, we were told, but unfortunately these things happen.
Yet the trust’s own postmortem report had found no infection. Sarah had showed no sign of an infection. The ‘evidence’ put in front of us made no sense. We were being gaslit, surrounded by red flags – it all felt like a cover up
As we fought for an independent review, Harriet’s body was kept in the hospital mortuary. Knowing our daughter was in the place that had failed to look after her, that we couldn’t pick her up and bring her home, was unbearable.
Only after an independent review concluded in 2018 that Harriet’s death was ‘almost certainly preventable,’ and had followed 13 simple, catastrophic and avoidable mistakes, and the hospital admitted liability, could we organise her funeral.
Sarah and Jack pictured with their daughter Lottie
At the time we had thought we were taking our daughter as we last saw her on her final walk in her tiny white coffin. Only years later, in 2024 did we learn the trust had allowed Harriet’s body to decompose in the hospital mortuary, to the extent her remains had to be wrapped in three bags so her bodily fluids didn’t leak in her coffin. There are no words to describe how this feels.
Given our treatment by the trust, it seemed to us inevitable that we were not alone, that this was happening to others. It was hard to find other families impacted at first because the hospital had done such a good job of isolating and blaming parents.
But in 2019 we got a message from Gary Andrews, whose daughter Wynter died 23 minutes after birth at the Queen’s Medical Centre of a brain injury that would have been preventable had she been delivered earlier. We became a team and set up a Facebook page for victims.
Ours is a group none of us wants to be in. But we’ve drawn enormous support from each other.
We’ve all been victims of people not doing their jobs well, making simple, avoidable mistakes. Is the answer more midwives and improved medical training? Perhaps. But there seems a wider culture, a disdain for pregnant women, that we need a public inquiry to excavate.
The trust killed our daughter, covered it up, then, through the ordeal of losing our jobs and having to fight to be heard, put us under enormous financial stress. In 2021 we were awarded £2.8million in compensation. This sounds a lot, but we’re still worse off financially than we were before. And our daughter is dead.
In 2022, when our group of families reached 100 names we wrote to Sajid Javid, then Health Secretary, to lobby for an independent investigation into maternity services at NUH.
We knew we wanted Donna Ockenden, at the time chairing the review into maternity failings at Shropshire and Telford NHS Trust, to lead the review. She has been kind, tough and forensically thorough, and done everything she can.
Harriet would have been ten this April. Milestones such as the day she would have started school, birthdays, Christmases – they’re all painful. Nobody tells you how to navigate this grief. There is an absence in our house, but Harriet is always with us. She is still our child. We hope she’d be proud that we’re fighting to make sure this doesn’t happen to anyone else.
As told to Antonia Hoyle
