The Nottingham Ockenden review identified that 444 women and 76 babies faced avoidable harm at Nottingham University Hospitals NHS Trust.
Persistent issues across the NHS include chronic understaffing, weak leadership, and a failure to listen to patients.
Maternity-related clinical negligence claims cost £2.5 billion in 2024/25, representing over half of total clinical negligence expenses.
Experts argue that retrospective reviews must transition into active, measurable safety improvements to prevent future tragedies.