Bad things have happened in maternity units. Babies have died. Women have been harmed. Families have been ignored, dismissed and left to fight for answers they should never have had to beg for.
Safe maternity care must be a national priority. But after more than a decade of investigations, one question has become unavoidable: have maternity reviews become a substitute for action?
Reviews can reveal what hospitals have hidden and give bereaved parents a public record of what happened. But reviews should lead to safer care. Too often, they have led to further reviews.
The same failures
The 2015 Morecambe Bay report found avoidable deaths of three mothers and 16 babies at one NHS trust, the organisation that runs one or more hospitals or local health services.
Seven years later, the Ockenden review of maternity services at Shrewsbury and Telford examined cases involving nearly 1,500 families and produced 15 national immediate and essential safety actions maternity services across England were expected to take.
Bill Kirkup’s East Kent report, Reading the Signals, in October 2022, avoided another long list of recommendations, identifying four broad areas for action instead.
The Nottingham Ockenden review, published on June 24 2026, is the largest maternity review in NHS history. It examined maternity and neonatal care at Nottingham University Hospitals NHS Trust between 2012 and 2025. The report found that 444 women and 76 babies suffered potentially avoidable harm because of substandard care.
The government has also launched a rapid national investigation to turn lessons from past reviews into one clear set of actions. That aim is sensible. But if the failures are already visible, what exactly are we still waiting to learn?
The recurring themes are familiar: too few staff, inadequate training, weak incident investigations, poor leadership, defensive cultures and women not being listened to. The Care Quality Commission, the regulator for health and social care in England, has also found continuing problems with women feeling unheard and unable to access help when they need it.
These failures have been written down repeatedly.
Reports are easier to publish than change
Reports create the appearance of progress. They announce actions, promise learning and produce timelines, boards, workstreams and action plans. But families are harmed when staffing is unsafe, warning signs are missed, concerns are dismissed and poor practice is tolerated.
The NHS and government have repeatedly treated publication as the dramatic moment, when the real test is whether maternity units change afterwards.
There is also a human cost to endless review cycles. A safety system that depends on repeated scandal, public exposure and retrospective investigation catches failure late. It leaves families to campaign while grieving, and puts exhausted staff under prolonged scrutiny without necessarily giving them what they need to work safely.
The evidence on staff pressure is serious. A systematic review found a consistent association between healthcare worker burnout and patient safety problems. The Royal College of Midwives’ Safe Staffing = Safe Care campaign says 45% of midwives report burnout often or always, and only 16% feel there are enough staff to do their job properly.
Reviews can expose unsafe care. They cannot, by themselves, staff a night shift.
Public reviews cost money. Sometimes that cost is justified. When families have been denied truth, transparency has a price. But money, time and clinical expertise spent on retrospective review are resources unavailable for frontline care, training and supervision.
According to NHS Resolution’s 2024/25 annual report, maternity accounted for 51% of the total clinical negligence “cost of harm”: £2.5 billion out of £4.9 billion. Clinical negligence means legal claims arising when healthcare is alleged or found to have fallen below an acceptable standard and caused harm.
Those figures are a safety warning. Preventing harm before families are forced into investigations, complaints and litigation is both morally urgent and financially sensible.
We already know some of the fixes
One of the most consistent findings across maternity reviews is poor communication: women not listened to, partners dismissed, families fobbed off, staff concerns ignored. A 2025 systematic review found that poor communication contributed to about a quarter of patient safety incidents.
Communication can also be improved. A systematic review and meta-analysis found that empathic and positive communication in healthcare consultations can produce small but meaningful benefits for patients.
Empathy training cannot solve unsafe maternity care on its own. It will not fix unsafe staffing, underfunding or weak clinical governance. But it directly addresses one repeated failure: women and families were not believed when they said something was wrong.
The practical agenda is clear. Hire and retain enough maternity staff. Protect time for training. Strengthen clinical leadership. Make boards accountable for delivery. Give families routes to escalation when they are frightened and unheard. Measure whether recommendations have changed practice.
Reviews have told us what is wrong. The next scandal will not happen because no one knew the risks. It will happen if knowing still does not lead to action.
