The publication of Donna Ockenden’s review into maternity services marks a significant moment for patient safety and accountability in the NHS.
The findings will be deeply distressing for the families affected. They point not only to serious and repeated failures in maternity care, but to wider systemic issues around transparency, leadership and the effective investigation of harm.
Medical Negligence lawyers at Stewarts specialising in complex birth injury and clinical negligence claims say the report reinforces longstanding concerns about how patient safety failures are identified, investigated and addressed.
Accountability and the case for a statutory inquiry
A striking feature of the review is the limited engagement from some senior leaders. While hundreds of staff and former staff contributed evidence, a number of senior executives declined to answer questions about their role during the period under scrutiny.
Guy Pomphrey Partner in the Medical Negligence team, comments:
“This report lays bare not only catastrophic failings in maternity care, but a profound failure of accountability at senior levels.
“For many families, the fact that key decision makers have not been fully scrutinised will reinforce the need for a statutory public inquiry with powers to compel evidence. Only then can we be confident that the full picture is understood and that meaningful lessons are learned.
“Without that level of scrutiny, there is a real risk that critical questions remain unanswered and that the opportunity for systemic change is lost.”
For affected families, “what happens next” will be as important as the findings themselves. There will be increasing focus on whether further investigation is needed to ensure full transparency and accountability.
Incident reporting and the integrity of patient safety systems
The review also raises serious concerns about how incidents were recorded and escalated.
In particular, the use of internal categorisation systems that appeared to avoid classifying events as serious incidents has implications for whether concerns are properly investigated and whether families are appropriately involved.
Guy adds:
“Another very troubling aspect of this review is the change to the incident reporting processes.
“Frameworks such as the Patient Safety Incident Response Framework are designed to ensure that incidents are recognised, investigated proportionately and, crucially, that families are involved from an early stage.
“Where organisations adopt internal systems that dilute or delay escalation, the effect is to obscure patient harm and to limit opportunities for learning. That undermines both patient safety and public confidence.”
A need for consistent, transparent application of safety frameworks
The Patient Safety Incident Response Framework places a clear emphasis on openness, learning and system wide improvement. Its effectiveness depends on consistent and transparent application across NHS organisations.
The issues highlighted in the review suggest that variation in practice can have serious consequences, particularly where reporting processes are not aligned with national expectations.
Stewarts’ team notes that timely investigation and early engagement with families are critical not only to improving outcomes, but also to maintaining trust.
Supporting families and driving change
Stewarts represents families affected by avoidable birth injuries and has extensive experience in holding healthcare providers to account.
The firm emphasises that many families turn to the legal process not only to secure financial support for lifelong care needs, but to obtain answers and drive improvements in patient safety.
Guy concludes:
“For families affected by failures in maternity care, accountability and transparency are essential. This report must act as a catalyst for change, ensuring safety systems are applied consistently and in the interests of patients, not institutions.
“The priority now is to ensure that lessons are implemented in practice and that no family experiences the same failings in future.”
