AN independent review of maternity services at Nottingham University Hospitals NHS Trust has found that 520 mothers and babies avoidably died or were harmed between 2012 and 2025. Senior midwife Donna Ockenden, chair of the review, discovered that 444 women and 76 new-born babies suffered ‘potentially avoidable’ outcomes. Ockenden listed about 2,500 maternity complaints. By any standards these were shocking findings.
Ockenden said: ‘A death of a mother or baby . . . should never be ignored.’
Health Secretary James Murray said he was ‘heartbroken’ to read of the Trust’s ‘neglect, incompetence, racism, discrimination, contempt and harassment’, that families had suffered ‘dangerously and tragically deficient care at almost every turn’, and that ‘the NHS failed them catastrophically’.
All the usual platitudes.
The Daily Mirror headlined its report: ‘Never Again’.
Yet as Martyn Pitman, a former consultant obstetrician and gynaecologist, tweeted: ‘Almost identical headlines were published after [Ockenden] chaired the maternity review at Shrewsbury and Telford back in 2017 and, despite her array of recommendations, exactly the same did happen. Again and again and again.’
Indeed.
‘Never again’ in truth means ‘nothing changes’. Inquiries follow scandals, followed by more scandals and inquiries. It goes on. Why?
Because none have executive powers. None are given the scope to investigate the structural causes that lie within the Kafkaesque morass that the NHS is today; none given a remit to follow up on any recommendations.
And each inquiry takes years. Ockenden has been investigating Nottingham since 2022. In August last year, then Health Secretary Wes Streeting appointed Baroness Amos to another, to investigate at least a dozen trusts with poor maternity and neonatal safety records.
Another inquiry was announced last October, this one into maternity complaints at Leeds Teaching Hospitals NHS Trust going back years. It won’t conclude until years from now.
In December 2025, Amos’s first report listed 748 recommendations for improvements in the reports produced by prior inquiries over the past decade. Yet she still has no executive powers to implement either their recommendations or her own. She described England’s maternity services as ‘much worse than anticipated’, telling BBC Radio 4’s Today programme that she had heard of women ‘being left in . . . rooms for hours on end’, and ‘bleeding out in bathrooms’. Women were ignored when they reported reduced foetal movement. Babies died without proper investigation. Some women felt blamed. Others complained of lack of empathy or apology for mistakes.
In response the politicians mouth the same platitudes. Streeting said ‘the systemic failures causing preventable tragedies cannot be ignored’. But they continue to be because the structure of unaccountability hasn’t changed. The inquiry, you could almost say, is there for optics alone, a political convenience to protect the unaccountable structure of the NHS.
Parliament’s Public Administration and Constitutional Affairs Committee counted more than 70 organisations involved in health complaints or investigations, of which, conveniently ‘no single person or organisation is responsible and accountable for the quality of clinical investigations or for ensuring that lessons learned drive improvement in safety across the NHS’.
The final recourse for complaint is supposed to be the Parliamentary and Health Services Ombudsman (PHSO) which reports to only one committee of Parliament, and which has misled MPs about its performance. Yet no parliamentary committee or politician can overrule it. It is an unaccountable quango which can choose for itself which complaints to investigate or reject, and it refuses more than 90 per cent. Any complaint about the PHSO itself will elicit the convenient response that it is independent.
As we’ve seen with the covid inquiry, British inquiries tend to be led by partisan judges and politicians, or members of the same profession being investigated, with self-interest in protecting the elite, except when they can throw a few political enemies under the bus. The terms of reference for such inquiries request investigation into ‘systemic failings’ but that system is never defined or specified. Notably, Streeting welcomed Amos’s interim report as if it gives insight into the system (a semantic frame he used three times).
In fact, none of the inquiries into maternity and neonatal care has ever investigated the ‘system’. Ockenden investigated one trust. Amos visited a few trusts, associated with local hotspots of baby deaths. Amos spoke with patients and staff – no leaders of the system, no experts on the system, no experts on systems in general. She did not track responsibility and accountability.
This pattern isn’t confined to maternity and neonatal care. Inquiries into other forms of care have found similar malpractice, made similar recommendations, similarly avoided the structure, and similarly failed to prevent repeat scandals. Instead, British medical professionals and their political masters chose to blame culture. Here are the exemplars.
1. The Lancet characterised the scandal at Stafford Hospital (run by Mid Staffordshire NHS Hospital Trust), where hundreds to thousands of patients died from poor care in the 2000s, as a ‘cultural crisis’.
2. In 2013, Julie Mellor, then the PHSO, criticised the NHS for a ‘toxic cocktail’ of a ‘culture of defensiveness’ and ‘a failure to listen to feedback’.
3. Later that year, a clinical professor completed an inquiry into safety within the wider NHS, which recommends a ‘zero harm’ culture, a legal duty for all healthcare workers to admit their mistakes, and ‘minimum staffing levels’.
4. In 2014, Health Secretary Jeremy Hunt promised an ‘open culture that learns from errors and corrects them’, following the example of the airline industry (a false analogy, incidentally).
5. In 2015, Parliament’s Public Administration Select Committee ‘commend[ed] the Secretary of State’s determination to tackle the culture of blame and defensiveness’.
Now, in 2026, Ockendon’s latest report uses the semantic frame ‘culture’ 434 times. That’s more than once per page. It uses the semantic frame ‘structure’ only 153 times, and usually inappropriately (such as to miscode the process as structure).
Baroness Amos’s interim report (which is tiny, by the way) uses the frame ‘culture’ nine times, ‘structure’ just twice (both times incorrectly).
Why blame culture?
Blaming culture ignores the structure, ie who is in charge, who administers, oversees, audits, investigates, promotes (or doesn’t) – and covers up.
Culture is nobody’s fault: it’s a collective fault, a majoritarian fault. It lies with no one. The buck stops with no one and never with the chair or CEO of the NHS Trust in question.
Until they are forced to resign or be held criminally accountable nothing will change. The lives of more babies and mothers will continue to suffer avoidable harm because real protection is concentrated on NHS management and their systems, which inquiries are not designed to investigate.
