Maternity care in the NHS is facing a decisive moment, with growing evidence that repeated inquiries are no longer driving safer outcomes. In this blog, Dr Richard Dune reflects on Donna Ockenden’s warning that the system already knows what is going wrong and must now focus on action rather than further investigation. Drawing on lessons from Shrewsbury, Nottingham and Leeds, he examines how workforce shortages, gaps in training, weak leadership and cultural failures continue to undermine safety. The article explores why implementation, accountability and competence assurance must now take priority if maternity services are to deliver meaningful, lasting improvement for mothers and babies.

Dr Richard Dune reflects on key insights from the Amaree Women’s Network Conference 2025, examining how women’s leadership, lived experience, and community-driven approaches are shaping more equitable, safe and sustainable health and care systems. Drawing on powerful voices from across health and care, this article explores how women are redefining leadership, culture, and system change, highlighting the urgent need for equity, belonging, and human-centred governance.

CQC ratings reveal the deeper systems that shape safety, culture and patient experience. In this blog, Dr Richard Dune examines why hospitals fall into an inadequate rating, what the CQC looks for when judging leadership and safety, and how services like Hull Royal Infirmary’s emergency department have begun turning fragile progress into meaningful improvement. He explores the structural issues that drive failure, from weak governance and unsafe staffing to poor IPC and medicines management, and shows how leadership, culture change and quality improvement can transform care. This analysis outlines what health and care leaders must prioritise to rebuild trust, strengthen compliance and move confidently from inadequate to good.

The murder of 10-year-old Sara Sharif in 2023 exposed devastating and preventable failures across England’s safeguarding system. In this blog, Dr Richard Dune examines the findings of the official Child Safeguarding Practice Review, which revealed serious breakdowns in information sharing, court processes, domestic abuse risk management, and professional oversight. He explores how flawed decisions, cultural hesitancy, and weak accountability allowed known risks to go unchallenged, ultimately costing Sara her life. The article calls for urgent systemic reform - stronger leadership, clearer thresholds, and integrated multi-agency working - to ensure no child is ever failed in the same way again.

Children’s mental health services in England have long been fragmented, creating barriers to timely and coordinated care. In this blog, Dr Richard Dune examines West Sussex County Council’s pioneering “Psychological Hub”, a unified, psychology-led model that brings together education, health, and social care under one leadership team. He explores how this integrated approach could simplify access, strengthen governance, and improve outcomes for children and families. The article also highlights lessons for health and care leaders on workforce capacity, data interoperability, and compliance, showing how joined-up systems like ComplyPlus™ can support safer, more effective, and sustainable mental health provision.