The announcement of a national rapid review into maternity and neonatal services in England is a critical and long-overdue step toward accountability and change. The government’s decision to initiate this investigation – set to begin with the most concerning trusts and deliver initial findings by December 2025 – signals a recognition that maternity safety is a national concern, not a series of isolated failures.
At Davies and Partners, we welcome this move and hope it marks a turning point in how the healthcare system treats the concerns, experiences, and grief of families.
Recent maternity inquiries haven’t led to lasting change
There have already been several major inquiries. The Ockenden Review into Shrewsbury and Telford Hospital Trust exposed nearly 300 avoidable baby deaths and injuries. Then came the East Kent review, which found at least 45 baby deaths might have been avoided, again pointing to a toxic culture and systemic neglect. Morecambe Bay, Nottingham – the list goes on. The BBC, The Guardian, and other outlets have reported on these again and again. Each report promises lessons learned. Each time, families hope it won’t happen to anyone else.
And yet, it does.
Each investigation has revealed avoidable deaths, serious harm, and a persistent culture of denial and deflection. The pattern is alarmingly familiar: parents reporting concerns are dismissed, systemic failures are overlooked, and lessons are learned too late, if at all.
That’s why we’re glad this new review isn’t just looking at isolated trusts but taking a national approach. That’s essential. Because these aren’t just local failings – they reflect something broken in the wider system. A culture that too often prioritises targets and image over care and compassion. A system that hasn’t reckoned with how race, class, and gender bias can affect outcomes.
The decision to approach this latest inquiry on a national level is the right one. A fragmented, trust-by-trust response cannot address what has clearly become a systemic issue. It is encouraging that the inquiry will seek to build upon the work of previous reviews and involve bereaved families from the outset. Their voices must be at the centre – not simply consulted but truly embedded in the process.
However, we must also sound a note of caution.
A “Rapid” Maternity Review must still be thorough
The framing of this as a “rapid review” raises legitimate concerns. The urgency is entirely justified – families should not wait years for change – but speed must not come at the expense of depth. If “rapid” becomes shorthand for “light-touch,” this inquiry risks becoming yet another missed opportunity. Families who have already endured unimaginable pain deserve more than symbolic action. They deserve tangible, enforceable change.
We are hopeful that the inquiry team and the Department of Health and Social Care ensure this review is comprehensive, inclusive, and rigorous. It must not simply repackage previous recommendations but build upon them with concrete, measurable commitments to safer care.
In particular, we call for:
• A commitment to binding reform—including statutory changes where necessary;
• Transparency, with interim updates to ensure momentum is maintained;
• Clear accountability mechanisms to guarantee recommendations are acted upon;
• A focus on equity, particularly addressing the racial and socio-economic disparities in outcomes;
• And a meaningful shift in maternity culture—toward listening, compassion, and trust.
This review represents an opportunity to rebuild public confidence and, more importantly, to save lives. But it must be more than a response to headlines. It must be a defining moment of reckoning – and of reform.
For the sake of every family who has suffered injury, loss or trauma, and for every expectant parent who deserves safe, respectful care, we hope this inquiry delivers not only speed – but substance.