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Dr Richard Dune
25-06-2025
Can the NHS fix maternity care before trust is lost forever?
Image by Pressmaster via Envato Elements
As families call for justice and professionals demand change, will this review be the moment the NHS finally puts compassion, safety, and equity first?
Stories of baby loss, maternal death, and institutional cover-ups have made national headlines for years. But behind each tragic story lies something even more alarming: repeated, systemic failures across NHS maternity and neonatal services. Now, in what has been described as a “line in the sand,” the Secretary of State for Health and Social Care, Wes Streeting, has launched a comprehensive national investigation to deliver long-overdue change.
In this blog, Dr Richard Dune explains why this time, it’s not just another review. It’s a call to transform a culture where too many families have been ignored, dismissed, or traumatised - and to build a future where safety, compassion, and accountability are the foundation of every birth experience.
What has been announced?
On 23 June 2025, Wes Streeting announced a two-part national inquiry into NHS maternity and neonatal care, following meetings with bereaved families and mounting public pressure. Backed by NHS England and the Department of Health and Social Care, the inquiry will:
- Deliver truth and accountability for families harmed by unsafe care
- Identify and urgently review the most unsafe maternity and neonatal services
- Consolidate findings from decades of investigations into a single reform plan
- Tackle inequalities in care for Black, Asian, and underserved communities
- Transform maternity care culture through co-production with staff and families.
“Maternity care should be the litmus test by which this government is judged on patient safety.”
— Wes Streeting, Secretary of State for Health and Social Care
“Maternity care should be the litmus test by which this government is judged on patient safety.”
— Wes Streeting, Secretary of State for Health and Social Care
“Maternity care should be the litmus test by which this government is judged on patient safety.”
— Wes Streeting, Secretary of State for Health and Social Care
“Maternity care should be the litmus test by which this government is judged on patient safety.”
— Wes Streeting, Secretary of State for Health and Social Care
The two-part approach
To drive immediate action while laying the groundwork for long-term reform, the inquiry will follow a two-part approach:
1. Local rapid reviews
The inquiry will immediately assess up to 10 of the worst-performing trusts - starting with University Hospitals Sussex and Leeds Teaching Hospitals. These reviews will deliver quick findings, offer closure to affected families, and inform the broader reform.
2. A national system-wide review
This stage aims to unify fragmented past inquiries - including the Ockenden (Shrewsbury and Telford), Kirkup (East Kent and Morecambe Bay), and Nottingham investigations - into one national plan. The final report is expected by December 2025.
Streeting has not ruled out a future public inquiry, depending on outcomes.
A timeline of tragedy
The UK has already endured years of damning maternity reports:
- Morecambe Bay (2015) - 11 babies and 1 mother died due to poor clinical skills and unsafe practices
- Shrewsbury and Telford (2022) - 201 baby deaths and 9 maternal deaths could have been prevented
- East Kent (2022) - At least 45 babies might have survived with appropriate care
- Nottingham (2023–2026) - Still ongoing, it may become the largest investigation yet with over 2,500 cases.
These events are not isolated. They represent repeated failures of leadership, oversight, and accountability.
The cost of inaction
Despite the hard work of NHS frontline staff, systemic issues remain:
- In 2024, the CQC found that none of the 131 maternity units it inspected were rated “Outstanding” for safety
- NHS maternity negligence claims now exceed the entire annual maternity service budget
- Maternal mortality among Black women is three times higher than white women; Asian women are twice as likely to die
- Maternal deaths have increased by 10% since 2009, even accounting for COVID-19 impacts
These statistics are not just numbers. They reflect real lives lost, families devastated, and deep inequalities in care.
Immediate government actions
In parallel with the inquiry, the government is introducing urgent reforms:
- A digital safety monitoring system in all maternity units by November 2025
- Targeted interventions by NHS England in failing trusts within a month
- An anti-discrimination programme to address racial disparities in maternal outcomes
- Creation of a National Maternity and Neonatal Taskforce, chaired by the Secretary of State, including experts, bereaved families, and sector leaders.
This task force will help shape the inquiry and co-design the national reform strategy.
Voices from the frontlines
Leaders across healthcare and advocacy sectors are rallying behind the initiative:
“Too many women are experiencing unacceptable maternity care... This must mark a line in the sand.”
— Sir Jim Mackey, CEO, NHS England
“Too many women are experiencing unacceptable maternity care... This must mark a line in the sand.”
— Sir Jim Mackey, CEO, NHS England
“Too many women are experiencing unacceptable maternity care... This must mark a line in the sand.”
— Sir Jim Mackey, CEO, NHS England
“Too many women are experiencing unacceptable maternity care... This must mark a line in the sand.”
— Sir Jim Mackey, CEO, NHS England
“The maternity workforce is on its knees… many are now leaving the profession.”
— Dr Ranee Thakar, President, RCOG
“The maternity workforce is on its knees… many are now leaving the profession.”
— Dr Ranee Thakar, President, RCOG
“The maternity workforce is on its knees… many are now leaving the profession.”
— Dr Ranee Thakar, President, RCOG
“The maternity workforce is on its knees… many are now leaving the profession.”
— Dr Ranee Thakar, President, RCOG
“Listening to bereaved families is vital. The bravery of campaigners has brought us to this moment.”
— Dr Clea Harmer, CEO, Sands
“Listening to bereaved families is vital. The bravery of campaigners has brought us to this moment.”
— Dr Clea Harmer, CEO, Sands
“Listening to bereaved families is vital. The bravery of campaigners has brought us to this moment.”
— Dr Clea Harmer, CEO, Sands
“Listening to bereaved families is vital. The bravery of campaigners has brought us to this moment.”
— Dr Clea Harmer, CEO, Sands
“Tailored care saves lives. Maternity services must be equipped to support multiple pregnancies.”
— Shauna Leven, CEO, Twins Trust
“Tailored care saves lives. Maternity services must be equipped to support multiple pregnancies.”
— Shauna Leven, CEO, Twins Trust
“Tailored care saves lives. Maternity services must be equipped to support multiple pregnancies.”
— Shauna Leven, CEO, Twins Trust
“Tailored care saves lives. Maternity services must be equipped to support multiple pregnancies.”
— Shauna Leven, CEO, Twins Trust
These comments underscore the need for meaningful culture change - beyond procedural fixes.
From blame to culture change
Time and again, bereaved families have described being:
- Ignored
- Gaslit
- Lied to
- Shut out of reviews
- Manipulated during investigations.
As Streeting acknowledged:
“What they experienced should never have happened, and we must ensure it never happens again.”
True reform requires restoring compassion, rebuilding trust, and creating psychologically safe environments for both staff and patients. Only then can we learn from failure instead of burying it.
Innovation must meet accountability
For lasting change, innovation must be part of the solution. That includes:
- Real-time digital risk detection and escalation systems
- Bias-aware clinical training to address inequalities
- Trauma-informed workforce development
- Co-designed services that prioritise lived experience.
The future of maternity care must be one where safety and dignity are standard, not exceptional.
Conclusion - This must be different
This national investigation presents an opportunity to finally get it right. Its success won’t be measured by the volume of its findings - but by whether five years from now:
- Fewer families are grieving
- Fewer midwives and doctors are burning out
- More women feel safe, respected, and heard during one of the most vulnerable times in their lives.
That is the legacy this review must leave behind.
Driving compliance through innovation
At The Mandatory Training Group, we recognise the scale of this challenge and the urgency of response. That’s why we’ve built ComplyPlus™, our all-in-one regulatory compliance platform designed to support healthcare organisations in embedding safety, accountability, and learning into everyday practice.
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- ComplyPlus™ Legal – Contracts, employment docs, and HR templates
From workforce training to incident reporting, audit trails to policy compliance, ComplyPlus™ helps organisations stay ahead of the curve, supporting safer outcomes for patients and staff alike. One platform. Endless possibilities.
About the author
Dr Richard Dune
With over 25 years of experience, Dr Richard Dune has a rich background in the NHS, the private sector, academia, and research settings. His forte lies in clinical R&D, advancing healthcare technology, workforce development, governance and compliance. His leadership ensures that regulatory compliance and innovation align seamlessly.
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