Patient Safety Watch: Much-needed taskforce inspires cautious optimism for change

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter. A busy edition, with some important – and at times difficult – developments to navigate.

National maternity taskforce gets going

The government has finally launched the new maternity and neonatal taskforce this week, to help deliver urgent improvements to the safety of services in England.

This is a welcome and much-needed step, and some truly excellent people are involved, including bereaved families, academics, royal colleges and charities. There are, however, some notable gaps. No human factors or safety science specialists are clearly represented, and some have pointed out the lack of anaesthetic representation – a significant omission given the crucial role anaesthetists play in managing some of maternity care’s highest-risk situations.

That said, the announcement makes clear that membership will evolve, so there is time to address these gaps.

After several false dawns over the past decade, this moment carries a degree of cautious optimism. Many will remember the promise of 2016’s Better Births review. The hope is that this time the system can move beyond recommendations and deliver meaningful, sustained change.

All eyes are now on the forthcoming National Maternity and Neonatal Investigation, chaired by Baroness Amos. Its recommendations, now expected in June, will feed into the taskforce’s work. 

Meanwhile, concerns about maternity safety continue…

BBC investigation highlights ongoing concerns at Oxford

A BBC News investigation has found that 58 baby deaths at Oxford University Hospitals Foundation Trust between 2019 and 2024 may have been preventable with better care.

Families described missed opportunities, poor communication and a defensive culture, with some internal reviews disputed by independent investigations that identified failings. 

Ockenden appointed to lead Leeds investigation

Since our last newsletter, there has been significant movement concerning Leeds Teaching Hospitals Trust, as health and social care secretary Wes Streeting has appointed Donna Ockenden to lead the independent investigation into maternity services there.

The decision follows sustained pressure from Leeds families and some MPs for the government to specifically commission Ms Ockenden to investigate after Mr Streeting previously decided not to.

Bereaved families have welcomed the announcement, but the process for commissioning the investigation and the time taken are worrying.

And while a process is now confirmed at Leeds, Sussex families are still waiting and are pushing for a Ms Ockenden-led investigation too.

My view? Previous major maternity inquiries have lacked formal evaluation, and it is increasingly clear that the system lacks a coherent and universally trusted approach. The time it has taken to reach this point in Leeds reflects just how limited the options are – a situation the Morecambe Bay Investigation predicted back in 2015, and one which could have been avoided had recommendation 44 of that report been implemented.

Are we now in a position where maternity investigations risk becoming reactive, inconsistent and influenced by lobbying, rather than part of a clear, established national process? A better system would surely be a standing, independent mechanism for similar investigations, with the capability, credibility and consistency (trusted by families and NHS professionals alike) to act quickly when concerns emerge, without families having to campaign for years to be heard.

In other patient safety news this edition…

NHS Staff Survey shows declining safety culture

The 2025 NHS Staff Survey paints a concerning picture for patient safety, with workforce pressures intensifying. More than two-thirds of staff said that staffing shortages prevent them from doing their job properly, while work-related stress has risen, now affecting more than 42 per cent of staff.

These pressures are translating into declining confidence in care, with only 62.8 per cent of staff saying they would be happy with the standard of care for a friend or relative.

Safety culture indicators are particularly worrying. Although 86.2 per cent of staff say their organisation encourages reporting of errors, only 67.3 per cent believe action is taken to prevent recurrence, and just 61 per cent receive feedback on changes made.

Confidence that organisations will act on concerns has fallen to 55.5 per cent, and only 47.6 per cent of staff believe action will be taken when they raise issues. Overall, just 60.3 per cent of staff feel safe to speak up.

The results paint a sobering picture, particularly as the Patient Safety Incident Response Framework, intended to strengthen learning, openness and improvement, is being rolled out. Instead, the data suggests frontline experience is moving in the opposite direction.

APPG on Patient Safety submits evidence to national investigation

The All-Party Parliamentary Group on Patient Safety has formally handed over its submission to the National Maternity and Neonatal Investigation.

The submission argues that maternity safety in the NHS is not failing due to a lack of recommendations, but a failure to implement them, with recurring issues including poor teamwork, weak accountability, fragmented care and defensive cultures.

It calls for a small number of structural reforms, including clearer clinical responsibility, stronger teamwork, reform of investigation processes, clearer standards for legal teams, and a national system to ensure recommendations are acted on.

Maternity investigation programme extended to 2030

The government has confirmed that the Maternity and Newborn Safety Investigations (MNSI) programme will continue until at least 2030, extending its role in improving maternity and neonatal safety across England.

Since 2018, MNSI has carried out more than 4,600 independent investigations into serious harm and deaths. The extension means this important work can continue, but the key question is whether learning from the programme is effectively translated into system-wide change. Without that, there is a risk of generating more recommendations without meaningful impact.

Martha’s Rule is saving lives

Official NHS England figures suggest that Martha’s Rule may already have contributed to saving more than 400 lives. Additionally, the figures show more than 11,000 escalation calls have been made, leading to just over 2,000 changes in care. 

Driven by the campaigning of Martha Mills’ parents and national NHS leadership, Martha’s Rule is now embedded in the NHS Standard Contract. The focus now shifts to full implementation and expansion into areas such as maternity and neonatal care.

Patients to be moved from ‘inadequate’ mental health hospital

NHSE has ordered nearly 300 patients be removed from St Andrew’s Northampton following serious patient safety concerns, including alleged staff assaults currently being investigated by the police.

As reported by HSJ, patients will be moved in phases, while an independent clinical team provides 24/7 oversight. The Care Quality Commission rated the hospital “inadequate” in November, and it has been closed to new admissions since last summer. 

Sharing some good stuff…

Baby Lifeline submission published

Baby Lifeline has published its submission to the National Maternity and Neonatal Investigation, bringing together a uniquely broad range of clinical expertise, patient safety insight and the lived experiences of families affected by harm.

The submission sets out seven priorities for change: workforce resourcing, safety culture, training, learning over blame, tackling inequalities, continuity of care, and stronger data systems. Coming from a charity that brings together such a depth of experience, it is well worth a read.

Study seeks patient voices

A really important study from King’s College London is seeking to hear from patients and families who have experienced harm in healthcare.

Led by Josephine Ocloo, the research focuses on “epistemic exclusion” – when patient voices are not heard or valued – and aims to better understand these experiences to improve patient safety.

If you or someone close to you has experienced unsafe care, this is a valuable opportunity to contribute to research that could help drive meaningful change. Interviews last up to 60 minutes, and participants receive £50. More information is available here.

Finally, if anyone is looking for some inspiration, I highly recommend this edition of Desert Island Discs with Stephen Westaby, an amazing man whose work has saved many lives.

That’s all for this edition. Thanks for reading. As always, we welcome your thoughts and feedback, and please look out for the next edition from Jeremy after Easter.

James