A review of maternity services in Nottingham found hundreds of mothers and babies suffered potentially avoidable harm or died due to "systemic failures"
ByMichael Buchanan
Social affairs correspondent
In November 2018, health bosses in Nottingham were told there was "a crisis in our maternity services". A letter, signed by more than 50 staff at the Queen's Medical Centre, warned "mistakes will be inevitable" if problems weren't addressed.
They told bosses of chronic understaffing, a scarcity of critical safety equipment and "a dire lack of leadership". But management reaction to the letter was "inadequate", its author told me recently. It was effectively ignored.
Wednesday's review of maternity services in Nottingham, external - reveals the shocking extent of the mistakes made. Hundreds of mothers and babies suffered potentially avoidable harm or died due to deeply embedded "systemic failures".
It is the fourth maternity review in little over a decade - all were heralded as being "never again" moments. But what happened to that letter goes to the heart of why maternity care in England is viewed as failing too many families.
It had been sent to the chairman of the Nottingham University Hospitals trust, as well as the chief executive, the medical director and the head of midwifery. Yet staff were palmed off. We know this because five years later, a new management team at the trust investigated what had happened.
Two weeks after the letter had been delivered, a response was sent to the staff outlining actions that had occurred over the previous few months, and offering to meet to discuss further. But the 2023 review found "no evidence" that the board had discussed the letter, with the new chief executive concluding that the response was "unsatisfactory". The review said: "It did not address the concerns that were being made."
That refusal by the trust to take meaningful action in light of a cry for help from its own staff highlights the repeated refusal for years by senior leaders across the NHS to improve maternity services.
Three maternity reviews preceded Nottingham – in Morecambe Bay, in Shrewsbury and Telford, and in East Kent. In all cases, the health service was aware of the problems but was unable, or unwilling, to get to grips with the extent of them until some determined families refused to take no for an answer. Those families pushed for the independent scrutiny that the NHS would never voluntarily conduct.
Donna Ockenden's inquiry into Nottingham University Hospitals NHS Trust maternity services found a "persistent failure to listen to mothers and fathers"
England's former health secretary Wes Streeting was fond of highlighting the 748 recommendations that exist across the health service for improvements in maternity and neonatal care. He argued it was proof the health service didn't need any more recommendations but simply needed to get on with making care better.
His answer was to create another review - a national maternity inquiry chaired by Baroness Amos - to bring all those recommendations into a slate of smaller, more focused actions. Her report is due to be published next week.
But if the Department of Health and Social Care and NHS England had ensured meaningful action had been taken sooner, many families argue there wouldn't have been the need for another inquiry – and that list of 748 recommendations would not have built up in the first place.
The day after the review into maternity failures in Shrewsbury and Telford was published, the then health secretary Sajid Javid promised "to go after the people responsible" for the failures. Four years later, there is no evidence that anyone in a senior leadership position has been held to account.
The Shrewsbury and Telford trust said this week it was "fully cooperating" with West Mercia Police, which launched an investigation six years ago into the trust's maternity service. No arrests have been made; police say they are carrying out witness interviews.
Maternity Failures: The Fight for Justice
As families demand answers for failures in maternity services, Panorama investigates how systemic neglect, inadequate staffing and a reluctance to learn from mistakes have led to heartbreak.
Watch on iPlayer now
And that gets to the heart of why some families are calling for a public inquiry into maternity care in England. Despite all the avoidable deaths and harms that have been revealed by these investigations, they see scant evidence that anyone in positions of authority has been held to account.
People have been allowed to retire or found other jobs within the NHS. The former chief executive of the Shrewsbury and Telford trust left months after it was put into special measures and moved into another NHS role - in Nottingham.
Regulators like the General Medical Council and the Nursing and Midwifery Council have never been held accountable for failing to step in and protect patients when families have reported egregious conduct to them.
The government says it is determined that the recommendations from the Nottingham review will not "sit on the shelf." It has also promised that NHS staff who refuse to engage with upcoming maternity reviews will be compelled to give evidence or face up to two years in prison.
With two further inquiries already announced – in Leeds and Sussex – that might focus the minds of some executives. But how might that work in reality? I'm told one former leader in Nottingham did speak to the Ockenden review but apparently couldn't remember much about his time at the trust. Would that count as engaging with the review if this law were in place?
These maternity inquiries each started with grieving families having to drag a reluctant NHS into acknowledging its failures. The health service has struggled to adjust to the modern era, where a doctor doesn't always know best and patients have a right to demand better care. Too often the NHS has given the impression that it is more interested in protecting its reputation rather than delivering safe care.
Until it embarks on a sustained and meaningful cultural shift, working cooperatively with patients and families, many fear it will continue to fail mothers and babies.