Why Donna Ockenden says maternity care needs action, not inquiry

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 followed comments by Wes Streeting, who suggested that the Government could consider launching a further statutory public inquiry into failings in maternity care. Ockenden’s response was measured but firm. Progress on the recommendations from previous maternity reviews, she said, had been “very disappointing”. The system, in her view, does not need another inquiry as a substitute for delivery.

This tension, between further inquiry and urgent implementation, now sits at the centre of one of the most serious patient safety challenges in modern healthcare.

In this blog, Dr Richard Dune reflects on the growing tension between further inquiry and urgent implementation in maternity care, highlighting that evidence and recommendations are already well established, yet progress remains slow and uneven.

Why Donna Ockenden’s voice carries weight

Donna Ockenden is not an armchair commentator. She is one of the most experienced and credible figures in maternity safety and system review in the UK.

Between 2017 and 2022, she chaired the independent review into maternity services at Shrewsbury and Telford Hospital NHS Trust. That review examined nearly 1,500 cases of maternal and neonatal harm and death, making it one of the largest maternity investigations ever conducted internationally.

The findings were devastating. Repeated failures to listen to women and families, a culture of defensiveness, poor escalation of risk, weak leadership, and an unsafe fixation on “normal birth” were allowed to persist for years. The final report set out more than 60 recommendations, many of which were framed as immediate safety actions. Crucially, the review did not uncover unknown risks. It exposed known risks that had been ignored.

Today, Ockenden is chairing another major review, this time into maternity services at Nottingham University Hospitals NHS Trust, covering cases stretching back decades. Interim findings have again pointed to familiar problems: inadequate investigations, poor record-keeping, failure to act on concerns, and limited learning from previous incidents.

When Ockenden says the system already knows what needs to be done, she is speaking from hard-earned experience.

The expanding landscape of maternity inquiries

Nottingham and Shrewsbury are not isolated cases. They sit within a growing national pattern.

Most recently, an independent inquiry has been launched into maternity services at Leeds Teaching Hospitals NHS Trust, one of the largest teaching hospital trusts in Europe. Families have raised concerns about baby deaths, communication failures, poor escalation, and inadequate responses to serious incidents.

Alongside local reviews, the Government launched a national maternity investigation in June 2025, with initial findings expected in February 2026 and a final report, including national recommendations, due in spring 2026. A National Maternity and Neonatal Taskforce is also being established to begin addressing systemic issues.

The volume of scrutiny is not the issue. The question is what happens next.

Ockenden’s case against another public inquiry

Donna Ockenden has not argued that accountability is unimportant. Nor has she dismissed the value of public inquiries in principle. Her concern is more fundamental: another inquiry risks repeating the same cycle without breaking it.

Her argument rests on several key points. 

First, the core issues are already well understood. Workforce shortages, gaps in training and supervision, inadequate funding, weak education pathways, and deeply embedded cultural problems have been identified repeatedly for years. Successive reports have described the same failure modes, often in strikingly similar language.

Second, families are being re-traumatised by delay. Each new inquiry reopens wounds while implementation drifts. For some bereaved families, further investigation feels less like accountability and more like postponement.

Third, there is a growing implementation gap. Recommendations exist on paper, but translation into everyday practice is inconsistent, slow, or partial. Ockenden’s frustration is not with learning, but with the lack of visible, measurable change.

Her warning is simple but uncomfortable: at some point, repeated inquiries stop being a solution and start becoming part of the problem.

Why the government is still considering an inquiry

From the Government’s perspective, the argument looks different. A spokesperson for the Department of Health and Social Care has made clear that a statutory inquiry has not been ruled out. Public inquiries, they argue, remain an important mechanism for establishing accountability, creating transparency, and ensuring lessons are formally captured.

There are also political and ethical pressures at play. Some families have explicitly called for a statutory inquiry, believing it offers a stronger route to justice, public acknowledgement of harm, and institutional accountability.

The Government has pointed out that statutory inquiries can take years and that its current focus is on a rapid national investigation, supported by a taskforce designed to move more quickly towards an action plan.

In other words, this is not simply a disagreement about facts. It is a disagreement over sequencing: whether the system should pause for another formal inquiry or press ahead with implementation, given the already overwhelming evidence.

What this debate reveals about maternity safety

Beyond the politics, the Ockenden–Streeting exchange reveals something deeper about how safety failures persist. Maternity harm in the NHS is rarely caused by a single catastrophic error. It emerges from systems where:

• Training exists, but competence is not assured

• Policies exist, but are not followed

• Risks are known but not escalated

• Staff speak up but are not heard

• Learning is promised but not embedded. 

These are not problems that require fresh discovery. They require disciplined execution, leadership courage, and sustained investment. Inquiry can expose failure. Only implementation prevents recurrence.

The training and workforce dimension

One of Ockenden’s most consistent themes is that workforce and training issues sit at the heart of maternity safety. Short staffing, inadequate supervision, skills fade, and poor access to meaningful refresher training all undermine safe care.

Crucially, training must be more than completion rates and certificates. It must translate into confidence, clinical judgement, escalation, and teamwork under pressure. Without that, even the most comprehensive inquiry findings will fail to protect mothers and babies.

This is where many organisations struggle. The gap between “training delivered” and “competence demonstrated” remains one of the most persistent risks in health and care.

Inquiry fatigue and the risk of normalisation

There is also a danger of inquiry fatigue. When serious harm repeatedly triggers investigations with familiar conclusions, organisations can become desensitised. Failure becomes normalised, and urgency dissipates.

Ockenden’s call is, at its core, a challenge to leadership: stop commissioning understanding and start commissioning change.

Where this leaves the sector

The reality is that both positions contain truth. Accountability matters. Families deserve answers. Transparency is essential. But so is speed, decisiveness, and delivery.

The national maternity investigation, due to report in 2026, will add further clarity. The critical test will not be the quality of its analysis, but the seriousness with which its recommendations are implemented, funded, monitored, and enforced. Without that, another inquiry, statutory or otherwise, risks becoming yet another chapter in a long history of avoidable harm.

Conclusion: From knowing to doing

Donna Ockenden’s intervention should not be seen as resistance to scrutiny, but as a demand for maturity in how the system responds to failure. The evidence is already there. The stories are already known. The risks have been mapped repeatedly. What is missing is not insight, but action.

For maternity care to become safer, the NHS must move decisively from knowing what is wrong to doing what is right, consistently, visibly, and without delay.

From findings to frontline change

At The Mandatory Training Group, we work with organisations and professionals across health and social care to close the gap between training, competence, and safe practice.

If your organisation is serious about learning from maternity inquiries, not just reading them, now is the time to review how training, supervision, and competence assurance actually operate on the ground. Our all-in-one regulatory compliance management platform, ComplyPlus™, supports this by providing a single, inspection-ready framework for evidencing training, competence, supervision, and regulatory compliance across services. 

Explore our latest resources, guidance, and online accredited training programmes designed to support safer care, stronger workforce confidence, and defensible compliance, because learning only matters when it changes what happens next.

Reference

Healthcare Management UK (2026) - Call for action on maternity care rather than another public inquiry.