Inside the Donna Ockenden Review of Sussex Maternity Services
Bereaved parents began giving evidence on 5 September at a public meeting in Brighton, marking the launch of an independent review into maternity and neonatal services at University Hospitals Sussex NHS Foundation Trust. The review is chaired by senior midwife Donna Ockenden (The Guardian).
An NHS Foundation Trust is a type of hospital trust in England that has greater financial and operational independence from central government. Neonatal services refer to specialised medical care for newborn babies, particularly those born prematurely or with health complications.
The review is expected to investigate more than 1,000 maternity and neonatal cases dating back to 2018. Its scope was confirmed by the UK Care Secretary in May 2026 (gov.uk), following Ockenden's formal appointment by the government in April (gov.uk). The launch followed months of campaigning by bereaved Sussex families.
Among the parents preparing to testify is Susan Cacciacarro. Her daughter Chiara, a first child, was diagnosed with a hole in the heart during a 20-week scan, making the pregnancy high-risk with regular monitoring. At 34 weeks, a scan showed Chiara had lost weight over a two-week period. Maternity staff at Worthing Hospital, run by University Hospitals Sussex, did not plan to expedite her birth, which was scheduled for 39 weeks. At nearly 37 weeks, Cacciacarro woke unable to feel the baby moving. Chiara was delivered stillborn.
The Sussex review follows a joint investigation by the New Statesman and the BBC, published in February 2026, which found that the deaths of at least 55 babies might have been avoidable with better care from University Hospitals Sussex. A separate independent review into Sussex maternity services, reported by the BBC in June 2026, found that hundreds of babies and mothers died or were harmed due to "deeply embedded systemic failures" in maternity care (BBC).
Ockenden's track record in this field is extensive. She led the landmark review into maternity care at Shrewsbury and Telford, whose final report in March 2022 examined the care of 1,486 families (gov.uk). She also led the review into maternity services at Nottingham University Hospitals NHS Trust and is chairing a parallel review into maternity and neonatal services at two Leeds hospitals.
At the Brighton meeting, Ockenden discussed the review's terms of reference with affected families. Child Bereavement UK noted that many parents who gave evidence to the earlier Ockenden maternity reviews were left bereaved of their baby and that those reviews highlighted many deaths as preventable (Child Bereavement UK).
The government's broader response to maternity review findings has included recruiting an additional 2,000 midwives and investing more than £149 million (gov.uk). In June 2025, Health and Social Care Secretary Wes Streeting ordered a rapid national investigation into NHS maternity and neonatal services (gov.uk). The following June, the government extended Martha's Rule to all maternity services, citing Ockenden's review as a reminder of the consequences when women, families, and frontline staff are not listened to (gov.uk).
Martha's Rule empowers patients and families to request a rapid second clinical opinion when they believe a patient is deteriorating. Think of it as an escalation button: when a family or staff member feels something is going wrong and the current care team is not acting, the rule gives them a formal pathway to bring in a fresh pair of eyes.
The trajectory from Shrewsbury to Nottingham to Sussex reveals a pattern that is becoming structurally familiar within the NHS: individual trusts failing to act on internal warning signs, national exposure through investigative journalism or family campaigning, and then an external review chaired by Ockenden whose findings confirm systemic rather than isolated failure. The Shrewsbury review alone covered 1,486 families. The Sussex review, at over 1,000 cases from a single trust across an eight-year window, suggests a comparable scale of potential harm. What distinguishes the current moment is that Ockenden is now simultaneously chairing reviews at three different trusts, an unprecedented workload concentration that reflects both the depth of her institutional credibility and the breadth of the problem her reviews keep uncovering.
The policy response has also escalated. Martha's Rule, which had not been extended to maternity services before June 2026, directly addresses one of the recurring findings across Ockenden's reviews: that clinicians dismissed or delayed acting on parental concerns, sometimes with fatal consequences. The Cacciacarro case, in which a high-risk pregnancy showing fetal weight regression was nonetheless managed on a routine delivery timeline, illustrates the precise clinical decision-making the rule is designed to challenge.
The broader context here is one of mounting pressure on the NHS to confront recurring, trust-level failures in maternity care. Ockenden is now the government's go-to figure for these investigations, and her simultaneous leadership of three reviews means her findings will likely shape national maternity policy for years. Whether the government's investment in additional midwives and the expansion of Martha's Rule can break the cycle that her reviews keep documenting is the question that will matter most to the families watching from Brighton and beyond.
In my view, the scale of what is being uncovered across multiple trusts points less to individual clinician error and more to a system that repeatedly fails to listen, escalate, and act on warning signs. The Cacciacarro case is devastating in its specifics, but it is the structural familiarity of the story that should concern anyone who cares about how these services are run.
