The Ockenden Review painted a deeply troubling picture of maternity care at Nottingham University Hospitals NHS Trust. It confirmed what families, NHS staff and previous reviews had been saying for years: not isolated mistakes but long-running failures across the service.
The Nottingham review examined the experiences of more than 2,500 families, more than 2,500 case reviews and engagement with over 800 current and former staff. It found that women and families were too often ignored, warning signs were missed and opportunities to prevent harm were repeatedly lost.
Within days, Baroness Amos’s National Maternity and Neonatal Investigation widened the lens by reviewing care across 12 NHS trusts. The same problems appeared across England. There were not enough staff, maternity services were struggling to cope with demand, leadership was often poor, organisations were slow to respond when harm occurred, and some groups of women experienced worse care than others.
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.
There must be real accountability. Some women and babies were harmed because individual professionals made poor decisions, failed to listen, ignored warning signs or fell below the standards patients have every right to expect. Where people have acted negligently, dishonestly or unlawfully, they should be held individually accountable. But individual accountability alone cannot fix the wider conditions that allowed these failures to recur across multiple organisations over many years.
But another inquiry, on its own, will not make maternity care safer. They make findings and recommendations to inform decisions made by others.
A statutory inquiry has legal powers to compel people to give evidence. That is one reason some families affected by maternity scandals are calling for one now. The Ockenden Review and the Amos investigation were independent reviews rather than statutory inquiries, so they did not have the same legal powers.
But statutory inquiries do not necessarily lead to better outcomes. They may be necessary where evidence has been withheld or witnesses will not cooperate voluntarily, but they can also take years.
Non-statutory reviews and investigations can be more flexible and quicker, although they rely more heavily on cooperation. What matters most is whether the process uncovers the truth, earns public trust, produces practical recommendations and makes sure those recommendations are acted on.
Endless investigations can also have unintended consequences. When staff spend years facing inquiries, legal claims and media attention, they may become less confident in their professional decisions and preoccupied with protecting themselves from future scrutiny, which affects their ability to respond to the needs of their patients.
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 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.
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.
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.
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 judgement confidently, communicate openly and focus on what women and babies need.
The Amos report describes similar pressures. 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 were also distressed by the gap between the care they knew women and babies needed and the care they were able to provide. This is therefore a patient safety issue.
We have seen the same pattern in our own research with maternity staff. Staff described losing confidence in their clinical judgment, doubting whether their employer would support them if something went wrong, and seeing public trust in the service collapse. Experienced healthcare staff left, or considered leaving, the profession altogether because they could not tolerate the personal and professional compromise they felt forced to make.
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.
The implementation problem is now difficult to ignore. The Amos investigation found a maternity system that was difficult to navigate, poorly coordinated and too slow to learn from mistakes. 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 but that 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 measures will only improve care if they are properly funded, given real authority, and backed by clear public accountability.
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 process to defer changes that existing evidence shows are needed.
Statutory inquiries are expensive and can take years to complete. The government’s response to the House of Lords Statutory Inquiries Committee found that statutory inquiries completed in the past five years took nearly five years on average – with little transparency or accountability over whether accepted recommendations were actually implemented.
Where individual professionals have acted negligently, dishonestly or unlawfully, that should be addressed through appropriate processes – professional regulation, disciplinary procedures, inquests where deaths are involved and, where the evidence warrants it, criminal investigation or prosecution.
The real question isn’t whether we need another statutory inquiry. It’s whether we can actually implement what we already know: act on Ockenden and Amos, fund the workforce and infrastructure needed to make change real, and measure progress publicly.
Scrutiny should continue – but it should be designed to make change happen, not trap the system in another long inquiry cycle while it waits to prove it can change.
