The publication of the Ockenden Report into maternity services at Nottingham University Hospitals NHS Trust marks an important milestone for maternity care in England. We welcome the dedication, transparency and depth of this independent review, and we recognise the immense courage of the families whose experiences have shaped its findings. Their willingness to share painful and deeply personal stories has created an opportunity for meaningful learning and lasting change.
The report makes clear that significant improvements are urgently needed across maternity services. It also acknowledges that racial, cultural and language inequalities continue to influence women’s experiences and outcomes.
At Support ME CIC, we share the ambition of improving safety, equity and trust in maternity care. As an organisation working closely with migrant, Muslim, Eastern European and other minoritised families, we wanted to examine one specific question:
Does the report’s approach to racial, cultural and language inequalities fully reflect the evidence it presents?
Our intention is not to criticise the report, but to contribute constructively to an important national conversation. We believe that recognising inequalities is an essential first step. The next challenge is ensuring that this recognition is translated into practical, measurable actions that improve care for every family.
What the report acknowledges
Our review of the report found that racial, cultural and language inequalities are clearly recognised throughout the document.
The report acknowledges that women from Black, Asian and other global majority backgrounds, women living in deprivation, migrant women and women with limited English proficiency experience additional barriers when accessing maternity care. It recognises that structural racism, discrimination, unconscious bias, communication barriers and a lack of culturally safe care can all contribute to poorer experiences and outcomes.
Importantly, the review team made specific efforts to hear from communities whose voices are often underrepresented, including migrant women, refugees and women with limited English proficiency. This demonstrates an awareness that these experiences must be part of understanding maternity safety.
For organisations like Support ME CIC, this recognition is significant and welcome.
Language is a patient safety issue
One of the strongest messages emerging from the report is that communication is fundamental to safe maternity care.
The report includes examples where professional interpreters were not available during complex antenatal discussions, fetal medicine consultations, postnatal care and follow-up appointments. In situations where women are expected to make informed decisions about their care, the absence of effective communication creates avoidable risks.
Language support should never be viewed as an administrative service or an optional adjustment.
Professional interpretation is a patient safety intervention.
If a woman cannot fully understand her diagnosis, explain her symptoms, ask questions, express concerns or give informed consent, her safety and the safety of her baby may be compromised.
One particularly striking finding within the report is that, among pregnancies involving babies who were small for gestational age and experienced adverse outcomes, English was not the mother’s preferred language in a significant majority of cases. While language alone is not presented as the cause of these outcomes, the report identifies access to skilled interpretation as an essential part of safer care.
This reinforces something community organisations have recognised for many years: communication is not separate from clinical care. It is part of clinical care.
Cultural safety matters
The report also highlights concerns around racism, discrimination and culturally inappropriate care.
It acknowledges that some women experienced discrimination because of their ethnicity, culture or background. It also includes testimony from NHS staff describing experiences of covert racism towards Black and Brown women, overt racism towards Eastern European women, poor experiences among Traveller, Gypsy and Roma communities, and inconsistent use of interpreting services.
These findings are deeply concerning.
They remind us that inequalities are not only about access to services. They are also about whether women feel listened to, respected, believed and safe throughout their maternity journey.
Cultural safety is not achieved simply by translating written information. It requires healthcare professionals to understand how culture, language, faith, migration experiences and previous interactions with healthcare systems influence communication, trust and decision-making.
Does the report go far enough?
While the report contains substantial evidence about racial, cultural and language inequalities, we believe there is an important question worth asking.
Do the final Immediate and Essential Actions give these issues the same prominence as the evidence presented throughout the report?
The report includes recommendations relating to accessible information, communication and translation where appropriate. However, there is no standalone Immediate and Essential Action focused specifically on:
- equitable access to professional interpreting services;
- culturally safe maternity care;
- anti-racist practice;
- reducing inequalities experienced by migrant and minoritised communities.
Given the evidence presented throughout the report, we believe these issues deserve greater visibility within future implementation plans.
This is not because equity should be viewed separately from patient safety.
It is because equity is patient safety.
For many families, communication barriers, cultural misunderstanding and discrimination directly affect informed decision-making, timely escalation of concerns, trust in healthcare professionals and access to appropriate care.
Where do we go from here?
The publication of the Ockenden Report is not the end of the conversation.
It is the beginning of the work.
If we want maternity services to become safer for every family, we believe future implementation should include:
- reliable, auditable access to professional interpreters throughout pregnancy, birth and the postnatal period;
- clear documentation of whether interpretation was offered, provided, declined or unavailable;
- longer appointments where interpretation is required;
- translated information that is culturally appropriate rather than simply translated word-for-word;
- meaningful partnerships with trusted community organisations;
- culturally safe models of care for migrant, Muslim, Eastern European, Black, Asian and other minoritised communities;
- education and training that addresses racism, cultural assumptions, language barriers and informed consent;
- equity measures embedded within governance, incident review, complaints and quality improvement processes.
These actions would not only improve experiences.
They would improve safety.
Our reflection
At Support ME CIC, our reflections are informed not only by the findings of this report, but also by our daily work alongside families navigating pregnancy, birth and postnatal care within the NHS.
Every week we meet women who struggle to understand appointment letters, who are unsure of their rights, who worry about asking questions because English is not their first language, or who feel their cultural or religious needs are misunderstood.
These experiences rarely make headlines.
Yet they shape how safe women feel throughout pregnancy and birth.
The Ockenden Report provides an opportunity that must not be missed.
If its recommendations are implemented alongside a stronger commitment to equity, anti-racist practice, culturally safe care and effective communication, it has the potential to improve maternity care not only in Nottingham, but across England.
Maternity care cannot be truly safe unless it is equitable.
We hope this reflection contributes constructively to the ongoing national conversation and encourages continued collaboration between healthcare providers, policymakers, researchers and community organisations working together to ensure that every family receives safe, compassionate and equitable maternity care.