The Ockenden Review into maternity and neonatal services at Nottingham University Hospitals NHS Trust was damning. It confirmed what families, staff and previous reviews have been saying for years: the failures in maternity care are serious, repeated and systemic.
The Nottingham review examined more than 2,500 family cases and engaged with more than 830 current and former staff. It found long-standing failures, including women and families not being listened to, poor responses when things went wrong and missed opportunities to act on concerns that were raised consistently by staff.
Within days, a second review by Baroness Amos – the National Maternity and Neonatal Investigation – widened the lens by reviewing care across 12 NHS trusts. It found consistent national patterns: staffing did not match demand, services were under pressure from rising complexity and capacity problems, leadership was lacking, responses to harm were often slow or defensive and inequalities affected women’s experiences and outcomes. Families affected by the Nottingham scandal are now calling for a statutory public inquiry into maternity and neonatal care across England, arguing that “safe care can only be consistently delivered when the full truth is known”. That call deserves to be taken seriously. Accountability cannot be treated as optional.
But a decision to hold another inquiry must take into account the fact that public inquiries do not, in themselves, deliver change. They make findings and recommendations to inform change made by others.
A statutory inquiry has powers to compel witnesses to give evidence. A non-statutory inquiry does not have these powers. However, it does not follow that statutory inquiries are inherently superior. Each type of inquiry has its own strengths. Statutory status alone does not guarantee greater learning, better implementation or safer care. Patients don’t necessarily benefit when healthcare staff are subjected to prolonged scrutiny through overlapping investigations and inquiries, litigation, regulation, media coverage and internal reviews over many years.
A study found that medical professionals changed their practice in response to fear of litigation, inquiries, complaints or professional regulation. Researchers call this “defensive practice”: when doctors, nurses or midwives make decisions partly to avoid blame or complaints, rather than simply because they believe those decisions are best for the patient.
In maternity care, that might mean ordering extra tests, asking senior colleagues to approve decisions the doctors, nurses and midwives would usually make themselves, recommending an intervention earlier than needed, or writing longer records because they fear being criticised later.
A midwife or doctor may spend more time recording why they made a decision than explaining that decision to a woman in labour. They may ask someone senior to take over, not because the situation has changed, but because they feel exposed. They may recommend the option that looks safest on paper, even when the woman’s circumstances are more complex.
Those actions are not automatically wrong. In some cases, they may be exactly what safe care requires. The problem arises when fear starts to shape clinical judgment.
An international literature review tells us serious failures must always be investigated. But investigations that drag on for years without leading to change can make staff more cautious and less confident, without making care safer. It can encourage staff to protect themselves rather than use their judgment confidently, communicate openly and focus on what women and babies need.
Amos supports this concern. Across the trusts reviewed, staff described burnout, stress and heavy workloads. The report says staff were working under intense scrutiny, fearful of making mistakes and operating in what they experienced as a blame culture. It also found that structural and systemic problems can make compassionate care harder to deliver. Staff wellbeing is therefore a patient safety issue.
Our own ongoing research, carried out with maternity and newborn care staff working under years of scrutiny by multiple bodies, found a similar pattern. Staff described losing confidence in their clinical judgment, doubting whether their employer would support them if something unavoidably went wrong, and seeing public trust in the service collapse. Experienced clinicians left, or considered leaving, the profession altogether, because the distance between delivering high standards of care and the care they were able to provide was too great. The impact on mental and physical health was significant, showing how poor staff wellbeing should be considered a patient safety issue.
The case for caution is stronger because the central problems are already extensively documented. Reviews into maternity failures at Morecambe Bay, Shrewsbury and Telford, East Kent and Nottingham have all identified recurring failures in listening, leadership, staffing, governance, safety culture and organisational learning.
Amos makes the implementation problem impossible to ignore. Its report found a maternity and neonatal system that is fragmented, overly complex and too slow to learn. It also examined why avoidable harm continues despite repeated reviews and recommendations.
The issue is no longer a lack of evidence about the main failures. Recommendations have not been translated into reliable change. The government has responded to Amos by announcing a Maternity and Neonatal Commissioner, a National Action Plan due in December 2026, new national maternity triage standards and additional investment in maternity and neonatal facilities. These steps will only improve care if they have authority, funding, transparency and clear accountability attached to them. Most importantly, a concerted effort to address the cultural issues that have created the conditions for poor psychological safety and impeded the delivery of compassionate care.
Families are entitled to ask why so many warnings were missed, ignored or minimised. But the government should not allow calls for another large statutory inquiry to defer changes that are already evidenced.
Statutory inquiries are slow and resource-intensive. The government’s response to the House of Lords Statutory Inquiries Committee noted that statutory inquiries completed in the previous five years took nearly five years on average, with insufficient transparency and accountability around the implementation of accepted recommendations.
Where people may have acted dishonestly, unlawfully or in breach of professional standards, that should be pursued through professional regulation, disciplinary processes, inquests (where deaths are involved) and, where the evidence warrants it, prosecutions.
Individual accountability should not delay organisational and cultural changes already recognised as urgent. The question is whether another statutory inquiry is an effective route to safer maternity and neonatal care, or whether the most urgent need is implementation with transparent accountability.
Acting on Ockenden and Amos’s recommendations will mean funding the workforce and infrastructure needed to make change real, measuring progress publicly, and giving services enough stability to rebuild trust.
Appropriate scrutiny should continue. But it should be designed to enable learning and delivery of safe, compassionate care.
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