Patient Safety Watch: ‘The wrong voices’

Good afternoon and welcome to the latest edition of the Patient Safety Watch newsletter. Unsurprisingly, maternity safety dominates this edition, after two major reports were published within a week of each other.

Ockenden review exposes scale of Nottingham maternity failures

The review into Nottingham University Hospital Trust’s maternity services, chaired by Donna Ockenden, found that 444 women and 76 babies experienced potentially avoidable harm because of substandard maternity care between 2012 and 2025.

Many of the themes the report highlighted are, sadly, familiar: failures to listen to women and families; inadequate fetal monitoring; delays in recognising and responding to deterioration; poor multidisciplinary working; poor leadership; and repeated failures to investigate incidents properly and learn from them. The report also found a “toxic bullying culture”, with a “small minority of powerful leaders” being allowed to “infect” the trust’s maternity services.

In response, the government announced several measures, including rolling out Martha’s Rule to all maternity units and new powers to compel NHS staff to cooperate with future maternity investigations.

At the press launch, Ms Ockenden said: “My team found examples of what they described as normalisation of deviance. This occurred when there were significant concerns that should have led to intervention, but the quest for normal birth continued – and avoidance of intervention persisted, often with tragic outcomes. These are not isolated incidents but were representative of a pattern. And that pattern caused long-term harm.”

The same issue – pursuing “normal birth” (birth without medical intervention) at the expense of safety – has been highlighted as a theme across multiple maternity inquiries and reports over the last two decades. Yet it has evidently still not been fully confronted or addressed – an issue I reflect on in the British Medical Journal.

National Maternity and Neonatal Investigation: actions and controversy

A second major report on maternity safety followed just a few days later. The National Maternity and Neonatal Investigation (NMNI), chaired by Baroness Amos, concluded that England’s maternity system is “confusing, inflexible, and unresponsive”. It highlighted longstanding problems, including workforce shortages, inconsistent investigations after harm, and a culture that too often failed to listen to women and families.

As reported by HSJ,  NHS England CEO Sir Jim Mackey has since written to trust boards announcing an immediate 10-point maternity improvement plan. Key measures include joint board-level accountability between medical directors and chief nurses, mandatory triage audits and improvements, rollout of Martha’s Rule, reviews of home birth services, action on inequalities, and strengthened board oversight to tackle the recurring safety failures identified by successive maternity inquiries.

‘The wrong voices’

However, controversy has surrounded the Amos report’s publication.

Shortly before the report was published, HSJ revealed that Bill Kirkup – the highly respected chair of the Morecambe Bay and East Kent maternity investigations – had resigned as an expert adviser over concerns that issues with “normal birth ideology” had been removed from the final report.

Speaking to BBC News, Dr Kirkup said: “We ought to acknowledge that this is a problem, and that it’s got patient safety implications for mothers and babies.” He added Baroness Amos had “listened to the wrong voices”, but did not disclose details on how the report was changed. 

National maternity adviser Michelle Welsh responded with a powerful and clear statement, and, as all-party Parliamentary group on patient safety chair, Jeremy Hunt has written to James Murray to raise concerns.

My view is that the Amos report contains several important recommendations. However, if its purpose was to consolidate the evidence, establish a shared understanding of why maternity failures persist, and unite the maternity community around the changes needed, it is difficult to see it as anything other than a missed opportunity.

Dr Kirkup is one of the country’s most respected patient safety experts. His decision to resign from a government-commissioned investigation and his subsequent public comments should concern everyone who cares about improving maternity safety.

Maternity professionals, harmed families and the public must be able to trust that national investigations won’t shy away from difficult issues, however uncomfortable the conclusions may be. If that confidence is undermined, so too is confidence in the recommendations and actions that follow. Those questions now deserve full transparency and urgent scrutiny.

In other patient safety news this edition…

Hughes calls for urgent action on patient redress

As reported by Sky News, patient safety commissioner for England Henrietta Hughes has urged the government to compensate people harmed by vaginal mesh and sodium valproate, saying those affected “deserve justice”.

More than two years after her report recommended a two-stage redress scheme, no compensation has been paid. Professor Hughes said the government’s failure to provide a substantive response has been deeply disappointing and warned that the ongoing delays are compounding the harm experienced by patients and their families.

Safety concerns remain at Hull Royal Infirmary

As reported by BBC News, the Care Quality Commission has found ongoing patient safety concerns at Hull University Teaching Hospitals Trust’s Hull Royal Infirmary.

The regulator again rated safety “inadequate”, citing continued staffing shortages, governance failures, and concerns over safe care, complaints handling and duty of candour. While inspectors praised staff’s compassionate care, they said wider systemic problems persisted.

The trust accepted significant areas needed improvement, adding that it had invested in additional nursing posts and strengthened its improvement plans.

Heatwave exposes NHS estate’s fragility

As reported by HSJ, June’s heatwave caused disruption across the NHS, with operating theatres closing, MRI scanners failing and hospitals declaring critical incidents as ageing infrastructure struggled to cope.

Hospitals in Sussex, London, Southampton and elsewhere were forced to postpone operations and appointments due to overheating and equipment failures. The disruption has renewed concerns about the NHS’s £16bn maintenance backlog, with clinicians warning that outdated buildings are increasingly unable to withstand extreme weather and calling for urgent investment to modernise the estate.

Families take legal action over paediatric hearing failures

More than a dozen families have brought clinical negligence claims against NHS trusts over paediatric audiology failings. These failings led to children’s hearing impairments being missed or underreported, causing delays in diagnosis and treatment.

As reported by HSJ, the legal action follows an NHSE review that uncovered widespread failings in hearing services, while Camilla Kingdon’s independent review concluded the NHS had underestimated the problem’s scale and lacked a reliable plan to address it. The government has yet to respond formally to the review’s recommendations.

Sharing some good stuff….

Group B Strep Awareness Week (8-14 July 2026)

Group B Strep is a leading cause of infection in newborn babies, including sepsis, meningitis and pneumonia. Group B Strep Awareness Week aims to raise awareness of group B strep and help ensure more families and healthcare professionals have access to the information they need.

Mary Dixon-Woods on patient safety’s future

THIS Institute has published an excellent blog summarising Mary Dixon-Woods’ keynote presentation to the APPG on Patient Safety in January. In it, Professor Dixon-Woods challenges some of the assumptions that have shaped the patient safety movement over the past 25 years, arguing that the NHS needs to move beyond generating ever more recommendations and instead strengthen its ability to understand problems, design effective solutions and evaluate what works.

That’s all for this edition. Thanks for reading. Please look out for the next edition of the Patient Safety Watch newsletter, which will now be out in September after a summer break.

James