Maternity Services - what next?
Maternity care is important for everybody.
What has gone wrong in maternity care?
Two recent reports have revealed serious deficiencies in maternity care. Donna Ockenden’s review of care at Nottingham University Hospitals examined 2,500 cases from 2012 to 2025. It is said to be the largest maternity review in NHS history. Ockenden identified systemic and deep‑rooted failings; in hundreds of cases harm or death of babies and mothers could have been avoided.
Key themes of the Nottingham enquiry included:
Poor fetal heart trace interpretation, and failure to recognise and escalate fetal distress
Unsafe triage; poor telephone advice and a culture discouraging women from attending
A bullying, toxic culture with racism, women’s concerns dismissed and staff unable to speak up
Unstable leadership and poor governance
Missed opportunities after multiple external reviews, CQC and NHS England warnings, and serious incident reports not being acted on.
Ockenden does not frame this as a handful of ‘bad apples’ in the workforce but as a systemic trust‑wide failure of leadership, culture, governance, and learning. Errors by frontline staff are a predictable consequence of a dysfunctional system.
The Care Quality Commission (CQC’s) National review of maternity services from 2022 to 2024 found a high level of performance in a only minority of maternity units. Just 4% were rated ‘outstanding’ and less than half ‘good’. The majority were ‘requiring improvement’ or ‘inadequate’. Recurring problems included weak risk assessment, inconsistent triage, poor escalation, and significant variation in safety standards between units.
The CQC report also highlighted workforce issues - chronic staffing shortages, rota gaps, recruitment and retention difficulties. These staff pressures undermine safety. The CQC stated that many maternity units were old and badly maintained, and not fit for purpose. Inequalities and racism, and persistent communication failures with women and families, echoed the findings from Ockenden’s Shrewsbury & Telford report and many other inquiries.
What are the causes?
The Nottingham and CQC reviews together stop short of a simple blame narrative but do distribute responsibility across levels, which they say have contributed to a ‘toxic mix’ across the service.
Leadership and governance failure: Hospital Boards and senior managers were repeatedly alerted to problems and ‘red flags’, but failed to act.
Culture and psychology: Bullying, blame, racism, and a lack of psychological safety, staff and families being ignored, concerns minimised, and poor learning from adverse incidents.
Staffing and workload: The National shortage of thousands of Midwives leads to inadequate rotas and high turnover. Staff became too thinly stretched stretched to deliver safe, compassionate care
Training and standards: Gaps in basic skills such as CTG interpretation, multidisciplinary teamwork, and emergency response, and a failure to prioritise continuous updating.
Systemic pressures and complexity: Rising maternal age, pre-existing medical conditions and high caesarean rates have not been matched by adequate provision of services, capacity, and skill mix.
Government policy: Longstanding workforce shortages, lack of a coherent maternity workforce strategy, and wider NHS austerity and capacity constraints
Whilst the Secretary of State calls it a scandal, we need to be clear where the blame lies. These reports tell us that although individuals are responsible for their practice, the current position is not primarily the fault of hardworking and overworked staff.
Frontline staff in Obstetrics and Midwifery are clearly making errors, which can be serious and repeated. However many of these staff are working in units which are understaffed, high‑pressure environments, with poor support and toxic working cultures. It becomes impossible to provide good care
The heaviest responsibility lies with leadership at trust and national level for allowing unsafe, under‑resourced, and toxic systems to persist despite clear warning signs, and with government for failing to ensure workforce and safety infrastructure kept pace with need.
It is crucially a problem of organisations and the wider system which tolerates and incentivises unsafe conditions, fails to provide adequate training, and fails to respond to warning signs. The root cause is a system failure rather than ‘bad’ or lazy’ staff.
I worked as a Consultant Obstetrician in the NHS for several decades and observed dedicated staff truing to provide the best service possible. However individual errors are happening, and are being repeated. These errors often lead to unforgivable outcomes for which staff have to take responsibility. But these errors are shaped by policy, resourcing, training, culture, and governance choices at Trust Board level and Nationally.
If you stifle empathy, care and vocation you end with staff who work by rote, according to the clock, and become fixated with completing the paperwork properly to the detriment of empathy. Following rigid guidelines is expected, and becomes more important than following clinical skills and instincts.
Front line staff training should be a priority but is so often cancelled or deferred because there are insufficient numbers of Obstetricians or Midwives on shift to release for training. Trainers are too busy to take time from essential duties. The system is creaking at its seams.
If you are someone working in Maternity Services and can see something of yourself in this piece, maybe it is time to stop and reflect? You should be able to provide care the way you want to, but if the concept feels distant, I would love to talk to you.
The first step could be to book a free no obligation 30 minute on-line conversation with me here. If I am not the right Coach for you, I will recommend somebody else who will be.
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