Last month, Health and Social Care Secretary, Wes Streeting, announced the launch of a ‘rapid national investigation into NHS maternity and neonatal services’.
This latest investigation follows a long history of inquiries and reforms, so it raises a familiar question: will this inquiry deliver real change where so many others have fallen short?
A system under strain
The announcement comes from ongoing concerns about the safety and quality of care more generally in England.
Such fears about safety have already led to a review of patient care being commissioned by the Department of Health and Social Care. The outcome of this review is the Dash Report, which was released last month (July 2025). The report has reached some very interesting, if somewhat unsurprising conclusions; despite increased focus and investment in safety over the past decade, improvements have been limited; many NHS recommendations lack cost-benefit analysis; the complaints system is confusing and unresponsive; and NHS data is underused for driving improvements, amongst others.
NHS Resolution is a group who provide guidance to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care. In their most recent annual report, looking back at 2024-2025, they shared that they had paid out a staggering £3.1 billion in compensation and associated costs on all their clinical negligence claims, but given that these claims can take several years to conclude, they estimated that the ‘annual cost of harm’ for their claims department was £4.9 billion.
What about maternity care – where does it fit in?
The NHS is regularly described as ‘on its knees’ and medical staff are demanding better pay, with many feeling overworked. So, it might seem shocking that so much public money is being spent on negligence claims which could have been avoided. To explain this, in the context of maternity claims, NHS resolution have said that “the high cost of compensation arising in maternity comes from a small number of very serious incidents resulting in brain injury to a baby at birth. These life changing injuries are devastating for the injured baby and their families and reflect the need to make provision for lifelong and complex care needs.”
However, maternity-related claims are still one of the top three most frequent types of complaints about care (along with emergency medicine and orthopaedic claims). In 2024-2025, 1,286 new claims were brought. Whilst this is a decrease of 107 claims from the previous year, 51% of the total clinical negligence claims relates to maternity – which equates to £2.5 billion. This is an increase from 49% of total claims in 2023-2024.
What’s the history of systemic maternity problems in the UK?
To understand the full picture, we need to look at the recent history of large-scale maternity issues in the UK, particularly those which have then led to the need for a dedicated review by an independent team.
Mid Staffordshire NHS Trust (2005 -2009)
Centred around the care provided at Stafford Hospital, most people remember the Mid Staffordshire scandal for its shocking estimated death toll – somewhere between 400 and 1,200 excess deaths between 2005 and 2009. In this particular case, the problems weren’t just about maternity care, but they included it.
Blame for the failures was laid at the feet of the trust’s board, who were said to have cut already low numbers of staff in order to make the necessary savings to pursue foundation trust status, and systemic failures at every point of the monitoring carried out by oversight organisations. An enormously in-depth enquiry was carried out, producing over a million pages of evidence.
Morecambe Bay NHS Trust (2004 – 2013)
The next scandal to break was at Furness General Hospital in Cumbria, where the negligence was this time limited to maternity care specifically. Between 2004 and 2013, at least 11 babies and one mother died unnecessarily due to poor maternity care. According to the 2015 Kirkup Report, based on an investigation carried out by Dr. Bill Kirkup, the result of the independent inquiry ordered by the government, staff there pushed for natural, midwife-led births even when medical intervention – like a caesarean – was clearly needed. Doctors were sidelined, concerns were brushed off, and there were even suspicions about missing medical records that could have proved (or disproved) concerns about the quality of care administered.
As with Mid-Staffs, although clinical care was at the heart of the issue, there were multiple failures in the systems and processes that should have identified and dealt with any issues far earlier than the point where they were actioned.
Shrewsbury and Telford NHS Trust (2000 – 2019)
Featuring a list of failures similar to that of Morecambe Bay, the problems with maternity services at Shrewsbury and Telford again involved a drive to push for natural birth over a caesarean even when parent and child safety was at risk, and poor-quality internal reviews which missed opportunities to identify failings and action improvements.
Over 20 years, babies and mothers died due to avoidable errors. Midwives at the Trust reportedly discouraged caesareans, even when there were clear signs of danger. Babies were left brain-damaged by failures to monitor heart rates. Some families were even told their babies had been stillborn when they hadn’t been.
These mistakes led to 295 babies dying or being left with brain damage that could have been prevented. The report followed an inquiry led by Donna Ockenden, a senior midwife, and provided a blueprint for improving maternity services, but sadly many of those changes have still not been actioned.
“We published [that report] in March 2022 and there were 22 immediately essential actions, as well as hundreds of actions for the NHS trust,” she said. “But with the chaos that followed in the year before the general election, things got lost and we are not as far ahead with those immediately essential actions as we should be.”
East Kent (2009 – 2020)
In 2022, another report – again led by Dr Bill Kirkup – was commissioned into maternity care provided at East Kent Hospitals. At least 45 babies might have survived if they’d received better care.
The themes are familiar: failures to monitor distress, poor clinical decisions, and a reluctance by senior management to both admit to and correct mistakes. What made this case stand out was the sense that hospital leadership was more concerned with protecting its reputation than protecting its patients. When mistakes happened, staff would look to minimise the seriousness and provide false reassurance, and when this wasn’t possible, a junior member of staff was often blamed instead.
Nottingham (Dates to be established)
Currently, the focus is on Nottingham University Hospitals Trust. The potential numbers are staggering – more than 1,800 cases are currently being reviewed in an ongoing investigation led once again by Donna Ockenden.
Though the full findings aren’t expected until June 2026, findings from an inquest into the death of a baby delivered at a trust hospital found her death had been “a clear and obvious case of neglect”, and just as at Mid-Staffs, staff have said low staffing levels are affecting patient care.
Will we ever learn?
Unfortunately, the key themes identified and the actions recommended after investigating all of these trust failures are very similar. Successive governments have made steps towards improvement, but in the face of systemic failure, there is only so much that can be done.
A step in the right direction?
The Dash Report sets out next steps and a 10-year plan, so we will have to wait and see what impact it has.
When it comes to maternity care more specifically, Donna Ockenden is now leading the largest-ever NHS maternity inquiry into Nottingham University Hospitals NHS Trust. Ms Ockenden has criticised the previous government for their failure to act on maternity care reforms, so will it be different this time?
Whilst a national maternity inquiry has been welcomed by many, including Donna Ockenden, she stresses that family voices must be central to reform. The long-term consequences of avoidable harm on health services and the economy are massive, but mistakes in maternity care don’t just cost money – they change families’ lives forever.
For now, it seems we will just have to wait and hope that the change in leadership in the UK will finally make maternity care safer for everyone.