The largest review in NHS history, Donna Ockenden’s independent review into maternity services at Nottingham University Hospitals NHS Trust, was released on Wednesday 24 June. The findings within the 400 page report were damning, highlighting “deeply embedded systemic failures” which led to hundreds of deaths and avoidable harm to babies and mothers.
Petals’ founder and CEO, Karen Burgess, reflects on the 45 minute address Donna Ockenden – herself a former senior midwife – gave on the release of the report, the report itself, and responds to the inclusion of Petals – following the cut of funding for our service at Nottingham University Hospitals NHS Trust.
I was struck by Donna’s forthright delivery of her speech yesterday. I believe she represents so many of us who have worked hard in the field of baby loss to bring attention to the needs of bereaved parents. We hear and echo Donna’s frustration, determination and unwavering commitment to see this through. To quote Donna:
“These are not high bars, they are the irreducible minimum that every woman in England deserves and has a right to expect. But we are not yet consistently providing it. We owe it to every mother, every baby, whose terrible experiences are recorded in these pages, to ensure that the failures described here are never repeated.”
I could not agree more.
The investigation and report featured contributions from more than 2,500 families. Devastating and harrowing stories include hundreds of women not being listened to and unimaginable, often tragically avoidable, outcomes including maternal deaths, the deaths of hundreds of babies and ongoing significant trauma. We welcome the report’s immediate, urgent recommendations, which are not only applicable to Nottingham, but to maternity services nationwide.
Petals’ power
One of the report’s recommendations is to improve psychological support for families affected by pregnancy and baby loss. Significantly, the report specifically names Petals, and notes that funding for Petals Counselling was withdrawn by the hospital’s Integrated Care Board last year. The inclusion of this detail of the loss of Petals counselling service underlines the vital role that our specialist baby loss counselling plays within the wider maternity and bereavement care pathway.
There is a wealth of evidence that the physical and mental trauma of baby loss can have profound and long-lasting consequences for parents’ mental health, relationships and wellbeing. No family should have to face that trauma without access to expert support. Petals Counselling is proven to improve the mental health of those who receive our therapy. Our mission is that Petals’ specialist counselling should be a critical component of compassionate, safe and effective bereavement care in every hospital.
Every baby. Every mother. Every bereaved family matters
At Petals, we remain committed to supporting families in Nottingham, as we have always been, and welcome conversations with the funders, to ensure that bereaved parents have access to the care they deserve at one of the most devastating times in their lives. A parent in the report describes how she was left to ‘sink’ following her loss. With Petals, nobody is left to sink.
Committed to collective action and change
In her address, Donna Ockenden called for ‘urgent, lasting, national change’ and ‘collective action’ to achieve safe maternity care. We at Petals stand alongside all those working across maternity settings, in the NHS, public and charitable sectors. We are resolute in our dedication to playing our part through the delivery of specialist mental health support to families who experience the loss of a pregnancy and baby, as we collectively strive to deliver maternity care that is compassionate, dignified, kind and safe.
As is recognised in Donna’s report, we have been here before. We desperately want yesterday to be the watershed moment it needs to be. We cannot afford to let the momentum slow. Donna said: “The time for reflection and talking has passed.” It’s clear what needs to change. We eagerly await the next steps with great interest and hope.

