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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.
On 5 January 2026, a familiar and uncomfortable debate resurfaced at the heart of NHS maternity care. Appearing on BBC Radio 4, Donna Ockenden delivered a stark message: the problem facing maternity services is no longer a lack of understanding, evidence, or investigation, but a failure to act. Her intervention...
Read more >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.
When the Care Quality Commission (CQC) rates a hospital service “Inadequate”, it is more than a regulatory judgement, but a signal of systemic risk. For organisations, it can trigger significant reputational damage, operational pressures, emergency improvement plans, and intense scrutiny. For staff, it can be deeply demoralising. And for patients...
Read more >The Lampard Enquiry is the first statutory public investigation into deaths in NHS mental health inpatient care, examining more than 2,000 cases in Essex. In this blog, Dr Richard Dune explores how its findings are reshaping the national conversation on patient safety, governance, and accountability across the NHS. He highlights how systemic failures in leadership, culture, and oversight have driven the need for reform, and why the enquiry’s lessons must translate into lasting change through stronger governance frameworks, digital compliance systems, and compassionate, learning-driven leadership.
When the Lampard Enquiry was formally announced in 2023, few anticipated just how far-reaching its findings would become. Now, as evidence continues to unfold, it is increasingly evident that this enquiry, examining more than 2,000 patient deaths across mental health services in Essex, will stand alongside the Francis Report and...
Read more >DNACPR mistakes in care: Governance, training and compliance - How poor DNACPR and resuscitation decisions highlight the urgent need for robust governance, digital compliance systems, and statutory training in care settings. "Action should be taken." - Coroner Darren Stewart OBE The recent BBC report into the tragic death of 74-year-old...
Read more >Is abolishing NHS England the reform we need? - The Mandatory Training Group UK - On 13 March 2025, the UK government made a historic announcement: NHS England will be abolished and its functions reintegrated into the Department of Health and Social Care (DHSC). Framed as the largest governance overhaul...
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