Leeds maternity enquiry: Can the NHS turn learning into change?

Yesterday’s announcement of an independent enquiry into maternity and neonatal services at Leeds Teaching Hospitals NHS Trust (LTHT) marks another difficult moment of reflection for the NHS, and for those who work tirelessly within it.

In this blog, Dr Richard Dune explores what this enquiry means for healthcare leadership, governance, and the future of safe maternity care.

For the bereaved families of Leeds, it’s a long-overdue step toward truth and accountability. But for healthcare leaders, it’s also a critical reminder that robust governance, transparent systems, and compassionate leadership are the foundations of safe, high-quality care.

This enquiry, ordered by Health and Social Care Secretary Wes Streeting, follows years of campaigning by parents who lost babies or loved ones in circumstances that were reportedly avoidable. It also raises a national question: why do the same systemic failings keep reappearing - and what will it take to ensure genuine, lasting change?

A long-awaited step for families seeking truth

Earlier this year, a BBC News investigation revealed that at least 56 babies and two mothers may have died avoidably at Leeds hospitals over the past five years. Dozens more families described traumatic experiences of inadequate care stretching back over 15 years.

Parents such as Amarjit Matharoo, Lauren Caulfield, and Fiona Winser-Ramm campaigned relentlessly for an independent enquiry after years of being dismissed, blamed, or ignored.

“None of us should know each other,” said Fiona Winser-Ramm. “The only place that we should have met is at a playgroup with our children. Instead, we’re supporting each other through the worst possible time. Our daughters deserved a voice, and we now have to be that voice.”

 — Yorkshire Evening Post, 20 October 2025

Their strength has brought long-overdue attention to a tragedy that extends beyond Leeds, exposing deeper questions about culture, leadership, and oversight within maternity care across the NHS.

A trust under scrutiny, and a culture of fear

Leeds Teaching Hospitals is one of Europe’s largest teaching hospitals, yet it remains an outlier in perinatal mortality. In June 2025, the Care Quality Commission (CQC) downgraded both maternity units at Leeds General Infirmary and St James’s University Hospital to “inadequate”, citing “serious risks to women and babies” and a “deep-rooted blame culture” that discouraged staff from raising concerns.

Whistleblowers reported that earlier positive ratings had masked deeper issues. For many families, the trust’s defensive response compounded their pain.

Newly appointed Chief Executive Brendan Brown issued an unreserved apology, acknowledging the lack of compassion and responsiveness in the trust’s handling of concerns:

“We are determined to do better. We want to work with families to make real and lasting improvements.”

For those working in regulated health and care services, this message underscores an essential truth: organisational culture is inseparable from patient safety. A culture that stifles voice and fear of blame inevitably leads to harm.

Leadership, oversight, and the challenge of accountability

The Leeds enquiry has reignited national debate about leadership accountability.

According to the BBC, families have called for the enquiry to examine what Sir Julian Hartley, Chief Executive of Leeds Teaching Hospitals until 2023, knew about maternity care concerns during his tenure. Sir Julian now serves as Chief Executive of the CQC, England’s national health and social care regulator.

In a statement to the BBC, Sir Julian said he was “absolutely committed to ensuring good patient care,” but accepted that “this commitment wasn’t enough to prevent some families suffering pain and loss,” adding, “I am truly sorry.”

Given his former position, questions have been raised about how the enquiry will maintain independence and public confidence. However, these are not questions about individuals alone: they highlight the need for clear governance, transparent oversight, and learning cultures that transcend organisational boundaries.

For health and social care leaders, this is a pivotal reminder: governance frameworks must not only exist on paper but actively drive safety, reflection, and accountability at every level.

Why Leeds matters - A national pattern of maternity failures

The enquiry in Leeds is not an isolated event. It follows a troubling pattern seen at Shrewsbury and Telford, Morecambe Bay, East Kent, and Nottingham University Hospitals, where repeated failures in maternity safety have come to light.

Each enquiry has uncovered the same underlying problems, including ignored whistleblowers, unsafe staffing levels, poor communication, and leadership defensiveness.

Despite powerful reports such as the Ockenden and Kirkup reviews, progress on implementing recommendations has been slow and inconsistent across trusts.

Announcing the Leeds enquiry, Wes Streeting said in a Sky News interview:

“This stark contradiction between scale and safety standards is precisely why I’m taking this exceptional step. We have to end the normalisation of deaths of women and babies in maternity units. These are people who, at their most vulnerable, placed their lives in our hands, and instead of being cared for, became victims.”

 — Sky News, 20 October 2025

For the NHS, and for every CQC-regulated provider, this enquiry should be seen not as a local issue but as a system-wide test of leadership, governance, and learning culture.

A call for leadership families can trust

Bereaved families have made clear their preference for Donna Ockenden to lead the enquiry, the midwife who headed the landmark investigations at Shrewsbury & Telford and Nottingham University Hospitals.

“No one else has the experience, expertise, or trust of families and staff,” said Amarjit Matharoo. “We’ve been clear that it must be Donna and her team.”

— Yorkshire Evening Post, 20 October 2025

Their call is about more than a name. It’s about trust. Trust that the enquiry will be thorough, independent, and compassionate, and that its findings will finally lead to systemic change.

Governance, culture and compassion - The systemic lessons

The Leeds enquiry exposes long-standing weaknesses in governance and culture that extend far beyond one organisation.

• Weak internal accountability - Early warnings from staff and patients often go unheeded or minimised

• Fear and silence - Teams operate under pressure, afraid to speak up

• Regulatory fatigue - Endless reviews and “action plans” create the illusion of progress without tangible change

• Lack of psychological safety - Without openness and trust, staff cannot learn or improve

• The human cost - Behind every statistic is a grieving parent, a traumatised clinician, and a system that must do better.

Governance frameworks and compliance systems, including digital tools for quality assurance, incident management, and risk reporting, can help create transparency and consistency. But technology and policy alone are not enough. Change requires leadership courage, moral accountability, and a commitment to continuous learning.

Restoring trust through transparency

Public confidence in maternity services depends on openness, compassion, and honesty, values that must guide every interaction, every investigation, and every response to harm.

Many families say the greatest pain came not only from the loss of their babies but from how the system responded: with silence, defensiveness, and denial.

Independent enquiries, though painful, offer an essential pathway to healing and change. But as healthcare professionals, we must go further by embedding continuous learning, reflective supervision, and digital compliance systems that make safety transparent, measurable, and sustainable.

For leaders in health and social care, the lesson is clear: transparency is not an act of exposure. It’s an act of integrity.

A moment of reckoning, and a call to learn

The Leeds enquiry comes at a time when public trust in healthcare is fragile. Workforce pressures, regulatory demands, and the legacy of COVID-19 have stretched every part of the system.

Yet this moment also offers a chance to redefine leadership and governance in health and social care. The enquiry’s findings will test whether the NHS, and by extension, every regulated organisation, can learn not just from failure but for the future.

As one bereaved father, Daniel Ramm, said:

“It’s been a long time coming. We’ve spent years trying to expose what we’ve known all along. Hopefully now, other families won’t have to go home with empty arms.”

— Yorkshire Evening Post, 20 October 2025

His words echo a simple truth: lasting improvement in maternity safety, and across all care settings, depends on a shared commitment to truth, learning, and compassion.

Towards a safer, kinder system

The forthcoming Leeds enquiry will likely review hundreds of cases spanning more than a decade. Its findings will test whether healthcare systems truly have the capacity, and the courage, to learn from history.

If its lessons are embedded, Leeds could become not just another tragedy, but a catalyst for meaningful reform across the NHS. A reminder that safety and compassion must sit at the heart of every decision, every process, and every culture of care.

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