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.