Caesarean rates have soared but reviving the campaign for ‘normal birth’ would be the worst possible response

In a decade, the share of babies born by caesarean in England has risen from roughly one in four to nearly one in two. Some blame the push for safer care and argue that inquiry reports exposing repeated harm, caused by pursuing ‘normal’ birth beyond safe limits, have ‘demonised’ vaginal birth and fuelled excessive intervention. That badly oversimplifies a complex picture, and it risks reviving the very ideology that helped cause the problem in the first place.

What has actually happened

The numbers aren’t in dispute. According to NHS England’s Hospital Episode Statistics, 26.5 per cent of deliveries in NHS hospitals in England were by caesarean in 2014-15. By 2024-25, the figure was 45.1 per cent. That year, for the first time, more babies were born by caesarean than by spontaneous vaginal birth.

Anyone who tells you that is a small change is not being straight with you. A caesarean is major abdominal surgery. It carries risks, including haemorrhage, infection and blood clots, and complications such as placenta accreta in later pregnancies.

But ‘the caesarean rate’ isn’t one number. It is two very different things added together.

Elective (planned) caesareans are scheduled in advance, either for a clinical reason, such as a breech baby, or because a woman has asked for one. They rose from 11.1 per cent of deliveries in 2014-15 to 20.0 per cent in 2024-25: an increase of 80 per cent.

Emergency caesareans are decided at short notice, usually during labour or when something goes wrong before it. They rose from 15.4 per cent to 25.1 per cent: an increase of 63 per cent.

Figure 1. Elective and emergency caesareans, England, 2014-15 to 2024-25. Source: NHS England, NHS Maternity Statistics 2024-25, HES national tables, Table 1.d. Percentages are of deliveries with a known method of delivery.

The two lines have different causes, and they mean different things. A rise in emergency caesareans can mean teams are spotting struggling babies sooner and acting, which is exactly what the inquiries asked for. It can also mean defensive practice.

Planned caesareans are the fastest-growing part of the picture, and they tell us something else: what choices women are making, and why. I’ll come back to that. First, the outcomes.

The other side of the ledger

Some commentators argue that caesarean rates have risen without any improvement in outcomes, and that this proves that the increases in interventions are ‘unnecessary’. That is wrong, and the facts need setting out clearly.

Fewer babies are dying

MBRRACE-UK, which tracks every baby death in the UK, reports that in 2024 the rate of stillbirths and deaths in the first four weeks of life was 4.77 per 1,000 births. In 2015, the year of the Kirkup report, it was 5.61. That makes perinatal mortality 15 per cent lower than in 2015. Behind every one of those figures is a family spared unimaginable heartache. Today, more than 700 babies a year go home with their families who would not have done had mortality rates stayed where they were in 2015.

Figure 2. Baby deaths in the UK, 2013 to 2024. Source: MBRRACE-UK Perinatal Mortality Surveillance: UK perinatal deaths of babies born in 2024, State of the Nation report (June 2026),

The stillbirth rate fell from 3.87 to 3.18 per 1,000 total births between 2015 and 2024. But a figure that particularly matters in this debate is the rate of babies who die during labour. Intrapartum stillbirths almost halved, from 0.37 to 0.19 per 1,000 births. That means 128 babies died during labour in 2024 compared with 288 babies 2015 – 160 fewer deaths.

Neonatal deaths rose a little after 2020, before falling again to 1.60 per 1,000 live births in 2024. Almost three in four neonatal deaths (74.3 per cent in 2024) are of babies born preterm. The recent rise may actually reflect something positive: more very premature babies now survive birth and are given a chance of life, even though, sadly, not all of them survive the first weeks. It is not evidence that care in labour has become less safe.

Fewer babies are brain-injured in labour

The second piece of evidence matters just as much, and has had far too little attention. The Maternity and Newborn Safety Investigations programme (MNSI) investigates cases in England where a baby born at term after labour shows signs of a possible severe brain injury, such as hypoxic-ischaemic encephalopathy (HIE): the injury caused when a baby is starved of oxygen.

MNSI reports that referrals of babies with a potential severe brain injury fell from 657 in 2020/21 to 431 in 2024/25, a fall of about a third. Confirmed severe brain injuries fell from 248 to 138, a fall of 44 per cent. Over the same period, the number of deliveries in NHS hospitals fell by only about 3 per cent.

In real terms, that means 226 fewer babies were referred to MNSI with a potential severe brain injury in 2024/25 than in 2020/21. Around 100 fewer babies a year now suffer a confirmed severe brain injury in labour.

Figure 3. Term babies referred to MNSI after labour with potential or confirmed severe brain injury, England, 2020/21 to 2024/25. Source: MNSI, “MNSI data show a fall in reported cases of HIE in England”

MNSI says the drop is “greater than the fall we might have expected to see in relation to the falling birth rate”. It adds that the fall has not been matched by any rise in intrapartum stillbirths or early neonatal deaths. And it concludes that “it is likely that this represents a reduction in England in the number of babies with HIE, born at term and following labour.”

It is worth looking at emergency caesareans on their own. Between 2020/21 and 2024/25, they rose from 18.9 to 25.1 per cent of deliveries in England. Over the same five years, MNSI referrals for potential severe brain injury fell from 1.17 to 0.79 per 1,000 deliveries, and confirmed severe brain injuries fell from 0.44 to 0.25 per 1,000. The two trends move closely together, in opposite directions.

Figure 4. Emergency caesareans (bars) and MNSI referrals per 1,000 deliveries (lines), England, 2020/21 to 2024/25. Sources: NHS England, NHS Maternity Statistics 2024-25, HES Table 1.d; MNSI, 4 March 2026.

This is an association over just five years, not proof that one caused the other. Planned caesareans rose over the same period too, and so did a great deal of national safety work on fetal monitoring and escalation.

Correlation isn’t causation. But that cuts both ways. Critics who treat the caesarean rate as self-evidently a disaster are drawing a causal line just as confidently. What the figures do show is that the rise in emergency caesareans has come alongside fewer brain-injured babies, not more.

As the President of the Royal College of Obstetricians and Gynaecologists, Dr Alison Wright, told the BBC, part of the rise reflects improvements “in our ability to detect when a baby’s wellbeing is deteriorating during labour”.

Why more women are choosing caesareans

The law changed

The Morecambe Bay report was published on 3 March 2015. Eight days later, the Supreme Court ruled in Montgomery v Lanarkshire Health Board.

Nadine Montgomery, who had diabetes and was expecting a large baby, was not told of the increased risk of shoulder dystocia, where the baby’s shoulders get stuck. Her son was born with severe disabilities. She said that, had she known, she would have asked for a caesarean.

The court held that doctors must tell patients about any material risks and any reasonable alternatives, judged by what matters to the patient, not by what doctors would choose to disclose. In maternity care, that means women must be told honestly about the risks of vaginal birth too. NICE’s caesarean birth guideline now says that if a woman still asks for a caesarean after discussion and support, she should be offered one. Any honest analysis of the rate since 2015 has to account for the fact that the law changed, decisively, that same month.

Mothers today are, on average, older and more medically complex. NHS figures show that in 2024-25 caesarean was the most common way of giving birth for every age group from 30 upwards, and accounted for 59 per cent of births to women aged 40 and over. NHS England has pointed to women’s choices and to rising rates of conditions such as diabetes and obesity.

Some midwifery academics, including Professor Soo Downe, argue that demographics alone can’t explain such a rapid rise. I think she’s right. Which brings me to the most important part of the story.

The loss of trust

Professor Downe suggests that many women now see a caesarean as “the least worst option”, because they fear they might not get the support they need for a “safe straightforward positive labour”. She is right about the first part but I think she has the second part back to front.

For a decade, women have read the same story again and again. At Morecambe Bay, failures of care were linked to the deaths of three mothers and sixteen babies, with some midwives pursuing “normal childbirth” “at any cost”. At Shrewsbury and Telford, Donna Ockenden found that 201 babies and nine mothers could or would have survived with better care, in a trust that took pride in its low caesarean rate and, in her own words, “pursued normal childbirth… at pretty much any cost”.

Dr Bill Kirkup’s 2022 investigation into East Kent, Reading the signals, found that:

“….the way in which ‘normal birth’ was spoken about and set out in material for mothers created an expectation that it was an ideal that staff and women should strive to achieve. On some occasions, this pressure of expectation seemed to contribute to staff decisions not to escalate concerns or to intervene, decisions that were otherwise inexplicable.”

At the trust’s VBAC (vaginal birth after caesarean) clinic, high-risk women were not told the risks. Decisions, the report said, must be “free from inherent prejudice about the ‘best’ method of delivery.” On teamwork, Dr Kirkup said:

“There is not a separate role to promote ‘normal’ birth or to reduce caesarean sections, or to be the ‘guardians of normality’, any more than there is a separate role to promote safety. A team that does not share a common purpose is not a team.”

Nottingham

Donna Ockenden published her Nottingham report on 24 June 2026. At its launch she said:

“Women who attended in early or advanced labour being turned away repeatedly, often after multiple calls for help… Women and their families who begged for caesarean sections had them denied repeatedly. We do not do caesarean sections for grandmother’s distress, the mother of a woman in labour was acidly told. Their baby, Sebastian, died… Throughout the review, 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 interventions persisted, often with tragic outcomes.”

What runs through all these reports is the same pattern: women who started on a low-risk pathway, whose risk changed, and whose care didn’t change with it. Worrying heart traces were explained away. Infections went unrecognised. Mothers asked for help and were told they were doing fine.

Women have absorbed this. Writing in the Guardian about choosing a planned caesarean, Sharon Gaffka described hearing women’s birth trauma stories: “Again and again, women said the same thing: ‘I wasn’t listened to.’” For her, a caesarean “feels like a way of mitigating the many uncontrolled risks that the Ockenden report explores in such horrifying detail.”

Who could blame her?

Here is the tragic irony. What has eroded women’s trust in maternity care is the fear that if something goes wrong, they or their baby could come to harm in a system that has too often prioritised achieving a ‘normal birth’ over a safe outcome. That is not irrational anxiety. It is a rational choice.

An ideology that treated intervention as failure, played down the risks of vaginal birth, and made midwives feel they had failed as ‘guardians of normal birth’ if they had to call an obstetrician produced exactly the unsafe care the inquiries documented. It is hardly surprising that trust has suffered.

The worst thing we could do now

Anyone who follows this debate knows how toxic it has become. Recent social media posts have accused me of ‘demonising vaginal birth’, and I’ve been blamed directly for driving an epidemic of unnecessary intervention that caused harm.

But I have never been against vaginal birth. Supporting physiological birth is an essential and hugely important part of good maternity care. What I oppose is promoting ‘normality’ in ways that systematically increase the risk of mothers and babies who need escalation and intervention – falling through gaps.

Some are now calling for maternity services to bring back the old approach: a return of ‘campaigns for normal birth’ and caesarean targets.

That would be the worst possible response.

What we should do instead

The rate itself must never be the goal. The goal is trust: so that a woman who wants to aim for a physiological birth can do so knowing she’ll be listened to, that changes in her risk will be noticed, and that help will come in time. That means:

• Honest information about both paths, and respect for a woman’s informed choice either way.
• Real support for physiological birth, from midwives with the time, skills and training to know when it’s no longer safe.
• One team with one goal: midwives and obstetricians working together as a single multiprofessional team, with escalation seen as good practice, never failure.
• Listening as a safety tool. “Something isn’t right” is clinical information.

Get this right, and the elective caesarean rate will settle wherever informed, well-supported women choose. It might be higher than in 2015, or lower than today. What matters is that it reflects choice and genuine need, not fear.

The rise in emergency caesareans needs to be interpreted with great caution and we must avoid simplistic assumptions. But it isn’t proof that the push for safety went too far. It has coincided with evidence that some outcomes, especially those you would expect to be associated with safer intrapartum care, have improved.

Others have commented that the rise in elective caesareans, is in part at least, likely to reflect an erosion of trust in maternity services. I think that is true.

Dr Alison Wright, President of the Royal College of Obstetricians and Gynaecologists (RCOG), has set out a vision for a system that I believe would go a long way towards restoring that trust. In her beautifully written blog post, Alison writes:

“A safety-optimised system would not promote a particular mode or experience of birth as the measure of success. The right birth is the birth that is right for that individual woman and baby, based on the clinical circumstances as they evolve and her informed decisions.

It would replace static concepts of risk with dynamic assessment throughout pregnancy, labour and the postnatal period. This would regard escalation not as a deviation from the intended pathway, but as evidence that the system is responding appropriately to changing circumstances.

It would replace professional silos with genuine multidisciplinary teamwork and shared accountability.

And it would combine compassionate reassurance with vigilance, curiosity and a willingness to act when something ‘does not seem right’.”

That is the path to fixing our broken maternity system and restoring trust. Not a return to targets and ideology.

Response to the Amos Report

My response to the Amos report can be read here.

Normal Birth – FinalDownload

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Thoughts on recent maternity safety announcements

July 2025

Earlier this month, the government announced two significant steps forward for maternity and neonatal care: a rapid national investigation into maternity and neonatal safety and the creation of a new maternity and neonatal safety taskforce.

I welcome these commitments wholeheartedly. Yet, the speed and ambition of the timeline – aiming to complete the investigation by December 2025 – also carries risk. If this moment is to deliver real, lasting change, we need depth, independence, and honesty about uncomfortable truths. And we must truly listen to those most affected.

Some key areas to consider:

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Independence and credibility start at the top

For this investigation to carry genuine weight and be trusted by families, frontline staff and the wider public, it should be led by someone independent of the English maternity system.

Panel membership must blend expertise in:

• Patient safety science and systems thinking
• Organisational culture and improvement
• Academic research and real-world clinical knowledge

Crucially, those directly familiar with day-to-day maternity and neonatal care must be at the table – but without fixed agendas or close affiliations that could limit objectivity.

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Valuing lived experience – and doing it properly

Inquiries and investigations often feature a small number of people with lived experience. I’ve been the ‘family voice’ on other national initiatives including the Better Births review in 2016. There are many lessons from that which I reflected on in my resignation letter at the time.

While the contribution of lived experience is vital, we risk hearing only a narrow slice of perspectives. Instead of having a few hand picked ‘family voices, the investigation should establish inclusive, representative lived experience reference groups to ensure that a wider range of voices are heard, especially those from marginalised or minoritised communities.

Engagement must also be trauma-informed and psychologically safe – supported by professionals trained to work sensitively with those affected by harm. And as a principle of respect, families’ time and expenses should always be recognised and compensated.

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Confronting uncomfortable truths about ideology and culture

One of the hardest – but most important – issues we need to tackle is the ideological pressure to achieve “normal” birth at the expense of safety. Too many families have suffered avoidable harm because interventions were delayed in pursuit of an unassisted birth.

The investigation should look closely at:

• How this mindset became embedded in policy, education, training and leadership
• The impact on teamwork, staff morale, and the willingness to challenge
• How we can foster a culture where personal choice and safety truly come first, rather than a single birth philosophy

“Maternity care debates often reduce birth to absolutes. One side champions birth as a natural, physiological process, resisting intervention (guarding ‘normality’); the other through the lens of risk and medical oversight. Neither captures the truth: birth is not inherently safe nor dangerous — it is both, until reality declares otherwise. A system designed for just one scenario is destined to fail.”

If we avoid this issue again, we risk repeating the failures of the past.

Avoiding simplistic explanations

The investigation must also resist looking for simplistic explanations and solutions.

For example, staffing levels are often cited as the primary explanation for unsafe maternity care. In reality, over the past 10 years the numbers of neonatal nurses, midwives, obstetrics & gynaecologists working in NHS hospitals in England have risen considerably.

Taking numbers of midwives as an example.

In 2009/10, there were 296 full-time equivalent (FTE) midwives per 10,000 deliveries in England. In 2023/24, there were 418 an increase of 41.2%. 

The graph below shows total changes in staffing levels per 10,000 deliveries since 2013/14.

Source:- https://jointpolicyunit.org.uk/data-hub/

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Broadening the investigation’s scope: data, systems and listening

Beyond culture, there are other critical areas to explore:

• A thorough review of maternity safety data, including changing demographics and public health trends
• Learning from high-performing systems here and abroad
• Assessing national programmes like MNSI and MSSP
• Exploring the development of a new national maternity and neonatal safety curriculum
• Examining how legal pressures and internal legal teams impact openness and learning – including the role of NHS Resolution (the CNST
  scheme in particular). Serious consideration should be give the longer-term reforms of the legal system and what we can learn from “no fault” systems as implemented in other countries.
• Understanding the additional harm caused by poor organisational responses after incidents – and how restorative practice could help heal, as seen in the ‘Harmed Patient Pathway’ project. (I’ve written about my own experience of healing after harm here.) The recently publish investigation in to maternity services at Swansea Bay has recommended the introduction of the Harmed Patient Pathway across Wales – surely we need the same in England?
• Embedding early detection and transparent responses and investigation to emerging concerns – it should not take grieving families years of campaigning before failing services are properly scrutinised. This was a key recommendation of Morecambe Bay Investigation (recommendation 43).

Listening must also be central. Too often, families report their concerns being ignored – sometimes with tragic consequences. We must break down the cultural and organisational barriers that stop staff listening and create psychologically safe environments where speaking up is valued and acted upon.

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What the taskforce must deliver

The new taskforce will be judged by its outcomes, not its existence. It should set:

• Clear, measurable aims to improve safety, reduce inequalities and enhance experiences
• Transparent tracking and adaptation when progress stalls – not a fixed list of actions to be ticked off
• Ongoing partnership with lived experience groups for real accountability
• Efforts to embed a just culture and tackle systemic barriers to openness and learning. This can only truly happen with system wide alignment. Culture is shaped by more than internal values, tools and checklists— it is also shaped by the external systems that surround it – more on that here.
• An ethos of ‘problem sensing’ as apposed to ‘comfort seeking‘ must be a golden thread throughout.

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A final thought

This is a rare chance to embed truly transformative change but previous efforts, including the ‘Better Births’ review in 2016, did not succeed. We must not make the same mistakes again. Success depends on independence, depth, honesty, real partnership with those most affected by harm and the courage to confront difficult issues.

As Bill Kirkup points out in this excellent podcast, long lists of operational recommendations (typically the output of patient safety investigations), however well intended – tend not to deliver change. The output of this work must be different – it must identify the system wide problems affecting maternity services as a whole and tackle these through a collaborative, evidenced based and properly funded plan – with progress tracked against real outcomes rather than ticked off actions.

Healing after harm

James Titcombe

(First published in Restorative Just Culture in Practice (Dekker, Oates & Rafferty, 2022).

In October 2008, our world was very different. Our daughter Emily was just three and a half years old, and at the time I was working as a project manager at a large nuclear facility on the North West Coast of Cumbria. At 7:38 a.m. on 27th October 2008, our second child Joshua was born at Furness General Hospital (FGH), part of the Morecambe Bay NHS Trust. I remember staring at him in his cot, thinking how perfect he was and how lucky I was—how lucky we all were. But just 24 hours later, that world ended.

An early morning phone call broke the news. I remember the words as if it were yesterday:

“Joshua is having problems breathing and your wife is very upset – can you come to the hospital?”

I remember phoning my mum and hearing her voice break (mums have an instinct), getting to the hospital and seeing Joshua in the Special Care Baby Unit—initially breathing by himself, but quickly put on a ventilator as I was ushered out of the room. Confusion, uncertainty, desperation, fear, hope, and despair followed.

Joshua was transferred by ambulance to a specialist unit in Manchester, and my wife and I followed him by car. At this point, we were uncertain as to what was wrong. We were told there might be a problem with his heart, but even then, the explanation didn’t seem to fit.

My wife had been feeling unwell in the days before Joshua was born, and shortly after his birth, she collapsed with a high temperature and was given intravenous fluids and antibiotics. She recovered quickly, but we both raised concerns with staff about Joshua—if my wife needed antibiotics, wasn’t Joshua also at risk of infection? Despite raising these concerns, we were repeatedly reassured that “Joshua was fine.”

Surely his collapse 24 hours later could not be due to infection? Not after we had specifically raised concerns with staff and been repeatedly reassured that Joshua was okay.

The following day, the team in Manchester confirmed our fears: Joshua had collapsed due to an overwhelming pneumococcal infection—the same strain that had now been identified as having caused my wife to collapse shortly after the birth. Questions about how this could have happened raced around my mind. Could I have done more to raise concerns and insist Joshua was seen by a paediatrician sooner? These feelings of regret and guilt have never left me.

But these questions had to be put on hold for now. Joshua was still fighting for his life, and all that mattered was getting him the right care and treatment so we could bring him home.

In Manchester, we were told that Joshua’s best option was to be flown to a specialist unit in Newcastle to be put on a heart and lung machine for babies. The treatment had risks, but the unanimous view of his clinical team was that it would give Joshua the best chance of recovery.

Joshua was flown by helicopter to Newcastle, and for a final time, my wife and I followed him by car. When we arrived, Joshua had already been hooked up to the medical machinery that we hoped would save his life.

We were greeted by a kind consultant who told us that Joshua’s prognosis was good and showed us a wall of cards, letters, and photos from the families of other children who had been cared for by the unit and had recovered and were now doing well at home.

We had seven hopeful days in Newcastle—Joshua sedated but able to open his eyes and squeeze a finger.

We hoped that we would get to take our baby boy home too, but that was not to be. Those hopes were dashed when Joshua died at just nine days old as a consequence of internal bleeding caused by the damage the pneumococcal infection had done to his lungs.

Although over a decade has passed since these moments, I remember them as vividly as if they had happened just yesterday. Seeing Joshua for the first time after his death, with all the tubes and medical equipment removed—he looked like a perfect baby boy. How could he have died for want of a simple dose of antibiotics at the right time?

The loss of any child, in whatever circumstances, is a life-changing tragedy—but coming to terms with Joshua’s death was made incalculably worse by the way the Trust and healthcare system responded.

Crucial medical records of Joshua’s observations went ‘missing’. Staff accounts of what happened at Furness General Hospital conflicted with what my wife and I remembered. The initial report from the hospital concluded that Joshua’s observations in the 24 hours after his birth were all within ‘normal’ limits and that therefore no one was to blame for what happened.

As Joshua’s father, I knew that no one intended the tragic outcome, but I was not going to accept false narratives and dishonesty either. I had failed to keep Joshua safe during his short life, but I wasn’t prepared to allow the truth about his death to be swept under the carpet.

I soon discovered that the healthcare system—at almost every level—was not open to looking for, let alone acknowledging, the truth about what happened to Joshua and why.

The journey since has been long, hard, and at times lonely. But eventually, we did establish a truthful account of what went wrong, and in doing so, uncovered a far wider scandal at the maternity unit at Furness General Hospital. After meeting other families who had experienced tragic outcomes following poor care at the same unit, I started a campaign group and worked to try and secure a national inquiry into the safety of the unit. The campaign was successful, and the Morecambe Bay Investigation report, chaired by Dr Bill Kirkup, was published in March 2015.

The report concluded that between 2004 and 2012, a ‘lethal mix of failures’ had led to the avoidable deaths of 11 babies and one mother at Furness General Hospital—Joshua was just one of many preventable deaths. It described the maternity unit as characterised by ‘denial and cover-up’. The report made 26 recommendations for national change and triggered a programme of work in England with the aim of halving avoidable harm in maternity units across the country by 2025.

In the aftermath of Joshua’s death, as well as struggling with deep trauma and grief, I was also consumed with a burning sense of injustice and anger. The more I learned about the culture of the unit where Joshua was born, the more I realised his death was far more than an unavoidable accident. The Kirkup report concluded that the Trust had its first opportunity to identify serious systemic issues following the avoidable death of another baby in 2004—more than four years before Joshua died. But the investigation carried out by the Trust was superficial, ‘protective of the staff involved’, and failed to result in any meaningful action to learn and make the service safer.

Why is transparency and learning so elusive in healthcare?

Human beings are prone to error. But where that normal variation in human performance can lead to serious or catastrophic outcomes—as in the nuclear industry or aviation—considerable effort is placed on designing systems and processes to prevent those mistakes leading to harm.

Joshua was born in a maternity unit characterised by dysfunction. Staff lacked basic competencies and skills. Processes and guidelines were out of date. Midwives and doctors perceived themselves to have different objectives, and there was distrust and blame in place of teamwork and shared goals.

Overriding all of this was a leadership culture that was toxic to transparency, learning, and improvement. The Trust at the time was preoccupied with achieving ‘Foundation’ status, which would have given them greater control and financial freedom—but crucially, this involved persuading regulators that they met the required standards of governance and quality. A dysfunctional maternity unit with a history of avoidable harm was a problem the senior leadership team sought to manage, focusing on reassuring the local community and regulators that services were safe.

Unpicking these behaviours is complex. The healthcare system seemed influenced by perverse incentives; pursuing strategic objectives and meeting performance targets seemingly placed above the safety of mothers and babies.

But the barriers to transparency and learning go much deeper. The truth is that existing systems, processes, and regulatory incentives often make it hard for healthcare professionals to do the right thing.

In the aftermath of harm, the relationship between the patient or bereaved family and the Trust can almost instantly become adversarial. In Joshua’s case, there was initially no inquest—we were told to raise concerns through a formal complaint.

Rather than our family and the Trust working together to understand and learn, the process became one of ‘allegations’ for the Trust to defend.

The vast majority of tragic outcomes like Joshua’s occur without deliberate intent—rather, they result from human error within unsafe systems. But healthcare staff often have little faith that internal investigations will be candid about systemic failings and fear being individually blamed or referred to regulators. Fear and safety cannot coexist. Healthcare systems must choose one or the other.

Dr. Lucian Leape said: “The single greatest impediment to error prevention is that we punish people for making mistakes.” He is right. Countering fear is crucial if we want to create the kind of learning culture that has made other high-risk sectors safer. Inappropriate blame detracts from where meaningful accountability should lie.

How could things be different?

Although it took nearly 10 years, eventually I reached a point of reconciliation, healing, and—to some extent—forgiveness.

After the Morecambe Bay Investigation report was published, the Trust agreed to further review Joshua’s death. Although several years had passed, they carried out the kind of investigation that should have happened from the start. The investigation highlighted failures already found by external reviews but also uncovered issues we hadn’t previously known. The key difference was that this time the Trust owned the process. For the first time, I felt they understood and accepted Joshua’s story.

The most difficult, but also most healing, part was a meeting with a midwife who had a direct role in Joshua’s care. She had been suspended for nine months by the NMC. Rather than immediately dismiss her, the Trust asked if I would be willing to meet her to discuss what happened. I agreed.

Until then, the only time I had seen staff involved was at Joshua’s inquest and formal hearings—bureaucratic, legalistic, and compassionless.

In preparation, I thought hard about what to say. I didn’t blame her for the mistakes and knew she hadn’t intended harm—but I needed to express how the lack of honesty afterwards had affected me and my anger at how little Joshua’s life seemed to matter.

When I began speaking, I got only halfway through. The midwife broke down in tears. She told me that every day since Joshua died, she had blamed herself—that she wished she had done things differently and would carry that for life. Her grief was genuine. The image I had of an uncaring person vanished. In that moment, my anger lifted. We cried together and hugged.

I left with a sense of healing, but also deep sadness—that we hadn’t been able to meet much earlier, and that in the years since Joshua died, humanity and compassion had been stripped from the process—just when kindness was needed most.

A welcome development in healthcare is the focus on Just Culture. If we want to prevent stories like Joshua’s, we must fundamentally change how the system responds to error and harm. Some changes that I believe would make a difference:

-Education and training on how to respond to clinical errors. Conversations about mistakes should be normal and not hidden. This must start in undergraduate training.

– Legal reform, so the system doesn’t act as a barrier to openness. Countries like Sweden have succeeded with ‘no-fault’ compensation that prioritises rapid learning and improvement.

– Cultural change, so healthcare professionals involved in serious incidents are not fearful of unjust blame or punishment.

– Restorative processes, so that healing after harm is possible—for both families and staff—and backed by investment in training and resources.

If we get this right, the aftermath of patient harm will no longer be defined by denial, fear, and blame—but by compassion, truth, and change.

We will see a shift away from individual blame and toward the accountability that matters most: that owed to future patients—to make sure the same mistakes never happen again.

Talk of Just Culture Without System Change Is a False Promise

James Titcombe – May 2025

In recent years, just culture has become a central concept in patient safety. In 2016, the report of the Expert Advisory Group set up by the government to advise on the creation of the Healthcare Safety Investigation Branch (HSIB)¹ described just culture as:

“… a shared set of values in which healthcare professionals trust the process of safety investigation; and are assured that any actions, omissions or decisions that reflect the conduct of a reasonable person under the same circumstances will not be subject to inappropriate or punitive sanctions.”

The key feature of a just culture — which distinguishes it from the outdated notion of ‘no blame’ — is the recognition that a line of acceptability in terms of individual actions and behaviour exists. Judging where that line is drawn (and when it is crossed) must involve understanding the system as it was at the time, and should be assessed through the lens of local rationality.²

In the absence of this, healthcare staff may fear a punitive response. Psychological safety³ is compromised — or absent entirely — and the conditions necessary for transparency and learning are set back.

Progress

The NHS has made concerted efforts to introduce and embed a just culture. Although it could be argued that the focus has leaned more toward what ‘just’ means for staff than for patients⁴, several well-intentioned initiatives have been introduced.

In 2018, NHS England published its Just Culture Guide⁵, based on James Reason’s Incident Decision Tree. While recognised at the time as a step forward, the guide has since been subject to high-profile criticism⁶ and is now considered to be out of step with principles of the Patient Safety Incident Response Framework (PSIRF).⁷

In 2019, NHS Resolution published its Being Fair guidance⁸, which includes a suite of resources aimed at supporting NHS organisations to foster cultural change.

Yet, despite these initiatives, there is little evidence of meaningful progress. NHS Staff Survey data shows that the percentage of staff who feel their organisation treats those involved in an error, near miss, or incident fairly — a useful, if imperfect, proxy for just culture — has barely shifted over the past five years: 59.7% in 2019, and by coincidence, exactly the same in 2024.

A New Tool

Against this backdrop, NHS England have recently published a new Being Fair tool¹⁰. The tool replaces earlier ‘just culture’ guidance and is intended to align more closely with PSIRF principles, offering a structured approach to supporting staff involved in patient safety incidents. It promotes accountability, prioritises emotional wellbeing, and encourages systemic analysis. It is practical and evidence-based. However, we should not fool ourselves into thinking it is sufficient.

The Broader System: A Barrier to Culture Change

In my work speaking with healthcare staff about barriers to cultural change, I hear a consistent message: changing culture requires far more than local policies or tools alone.

When something goes wrong, healthcare staff may find themselves navigating a bewildering and sometimes isolating terrain. Internal learning responses are only part of the picture; there may also be a Coroner’s inquest, a referral to a professional regulator, or even a national inquiry or police investigation. While each process plays a legitimate and important role, uncertainty around how these external systems will respond — and how the facts will be contextualised — can erode trust and psychological safety. This is true even in organisations where staff are confident that local processes will treat them fairly.

Take inquests, for example. Though designed to be inquisitorial rather than adversarial, they often feel quite the opposite — both for healthcare professionals and bereaved families. Few coroners have training in systems thinking, human factors, or the concept of local rationality, which are essential to understanding why people act the way they do in complex environments. This can result in a disconnect between the inquest process and the approach taken under PSIRF, which emphasises learning and taking a systems perspective.

Moreover, coroners are increasingly invoking Article 2 of the Human Rights Act in inquests involving potential patient safety issues. While this can be appropriate, it often broadens the scope of the inquiry significantly — requiring the court to explore a wide array of contributing factors. Yet without a grounding in safety science, there’s a risk that this exploration remains superficial or focuses unduly on individual actions rather than systemic conditions. If we are to make genuine progress towards a just culture, the inquest system too must evolve — embracing the same principles of just culture and systems thinking that underpin local learning responses or investigations.

The media also plays a critical role. While its function in exposing failings and amplifying the voices of harmed patients and families is vital and often done with utmost skill and professionalism, it sometimes lacks nuance. Complex events can be reduced to simplistic, blame-focused narratives that shape public perception and heighten fear — further compounding the challenge of building psychological safety within organisations.

Patients and Families

Equally critical — and too often overlooked — is the experience of patients and families. The same system that harms patients frequently harms them again in the aftermath, through defensive processes that prioritise reputational protection over truth, learning, and empathy. This results in compounded harm, where the suffering caused by the original incident is intensified by how the system responds.¹¹ A culture cannot be described as just if it marginalises and further harms the very people it exists to serve.

New initiatives such as the Harmed Patients Pathway¹² and a shift towards restorative practice and principles in response to harm in healthcare, may go some way toward redressing this imbalance, but much more needs to be done.

What Needs to Change?

Reforming the broader system — coronial, legal and regulatory — is essential to achieving a truly just culture.

• Coroners’ courts should adopt a systems-based approach, with training in human factors to better understand error in context, and with better support for both healthcare staff and families.
• Regulators, including the NMC and GMC must clearly distinguish between accountability and culpability, ensuring that referrals are proportionate and fitness to practice processes informed by a deep understanding of systems thinking.
• Media engagement could be guided by a voluntary code of conduct that supports balanced, contextualised reporting.

Most crucially, there needs to be a much clearer, more explicit focus on what a just culture means for harmed patients and families. Those harmed by healthcare deserve not just transparency and candour, but compassionate support that enables recovery — both emotional and practical.

The NHS has made progress: the language of safety is more sophisticated; safety science and human factors is becoming more and more integrated into everyday work  and tools like Being Fair represent the right intent. But culture is shaped by more than internal values, tools and checklists— it is also shaped by the external systems that surround it.

Until we challenge and reform those wider systems, a just culture in our healthcare system will remain an aspiration.

References

1. HSIB Expert Advisory Group Report
2. Local Rationality | SKYbrary Aviation Safety
3. Psychological Safety – Amy C. Edmondson
4. https://www.hsj.co.uk/patient-safety/a-just-culture-for-both-staff-and-patients/7025942.article
5. NHS Just Culture Guide
6. NHS Improvement’s Just Culture Guide: good intentions failed by flawed design – Bill Kirkup, 2019
7. Patient Safety Incident Response Framework
8. Being Fair – NHS Resolution
9. NHS Staff Survey
10. Being Fair Tool – NHS England
11. https://onlinelibrary.wiley.com/doi/full/10.1111/hex.13478
12. AvMA – Harmed Patient Pathway

From ‘Comfort-Seeking’ to ‘Problem-Sensing’

James Titcombe

The emerging scandal around the misdiagnosis of hearing problems in hundreds of children, as reported by The Sunday Times last week¹ , is more than just a tragic failing—it’s a mirror held up to a deeper, persistent issue within our healthcare system, reflecting a culture where the primary concern is often not “what might be going wrong?” but “how can we show that everything is okay?”

At least 775 children across England have been recalled by hospitals amid fears they were misdiagnosed after hearing tests between 2018 and 2023, with 107 already confirmed to have suffered serious harm. Many were wrongly labeled deaf due to poorly interpreted auditory brainstem response (ABR) tests, when hearing aids or cochlear implants could have helped. This isn’t just a diagnostic error—it’s a symptom of a healthcare system that too often appears more focused on protecting itself than protecting patients.

Speaking to The Sunday Times, Wes Streeting said: “Early diagnosis of hearing issues is vital – the first few years are a crucial window for speech and language development that, once missed, cannot be fully recovered. And yet years passed without sufficient action being taken by senior leadership… That is unforgivable.”

Streeting went on to describe the scandal a “profound breach of trust”, typical of “…an NHS culture that buried problems rather than confronting them head-on.”

An inquiry, led by Dr. Camilla Kingdon, is now underway to uncover why these failures went unchecked. But one lesson is already clear: when leaders focus more on reassuring themselves that everything is under control than on actively looking for warning signs, people are hurt.

Comfort-Seeking vs. Problem-Sensing

This brilliant paper by Mary Dixon-Woods and Graham Martin² sets out the contrast between organisational cultures that seek comfort and those that support ‘problem-sensing’. In ‘comfort-seeking’ cultures, there is:

– An overreliance on reassuring data

– A reluctance to challenge the status quo

– A tendency to avoid information that might suggest risk or failure

Conversely, problem-sensing cultures actively seek out system weaknesses, use diverse forms of intelligence, and normalise discomfort as part of improving safety.

This distinction defines NHS scandals. From Bristol to Mid-Staffordshire, Morecambe Bay to Shrewsbury and Telford – the inquiries into what went wrong all highlight warning signs that were missed, concerns that were dismissed, and opportunities to intervene that were lost.

Time and again, the same pattern emerges: signals of harm are buried, and the instinct to protect reputation overrides the duty to protect patients.

Breaking the cycle

Calls for criminal sanctions for cover-ups—such as those proposed under the ‘Hillsborough Law’³—are understandable, and arguably necessary. But if we want lasting cultural change, we also need to look at the system itself.

Does the current system support NHS organisations—and the leaders and staff within them—in actively promoting a ‘problem-sensing’ culture? Or do regulatory frameworks, NHS Resolution incentive schemes (which tie financial rewards to self-declared compliance), top-down performance pressures, litigation, and prevailing attitudes from commissioners to NHS England and the Department of Health itself, incentivise compliance on paper over curiosity in practice?

We need to ask: does the system make it easy for leaders and NHS staff to embrace ‘problem-sensing’—or does it make it harder?

We need a healthcare system where:

– Patient concerns are listened to and acted upon in real time

– Seeking out problems is a routine and rewarded part of everyone’s jobs

– Investigating anomalies is viewed as a strength, not a threat

– Raising concerns is embraced as a vital safety mechanism and encouraged and rewarded—not treated as reputational risk

We need leaders who don’t ask, “How do I protect the organisation’s image?” but instead, “What might we be missing?” and “Who else might be at risk?”

As the NHS prepares its next 10-year strategic plan, there is a unique opportunity to reshape the system around what truly matters: openness, responsiveness, and continuous learning. This demands a fundamental shift in mindset—from protecting reputation and seeking reassurance, to protecting patients and embedding a culture of ‘problem-sensing’ at every level.

1. https://www.thetimes.com/article/1e20d174-3952-48ba-a008-8d32db46f42c?shareToken=c53f6327871cc3d8161205a95db9d319 ↩︎
2. https://nhsproviders.org/media/695531/culture-and-problem-sensing.pdf ↩︎
3. https://www.bbc.co.uk/news/articles/cgjl5v9dzdzo ↩︎

Schrödinger’s Baby: The Uncertainty of Childbirth and the Need for a Maternity System That is Safe for All

James Titcombe – April

In quantum mechanics, the famous thought experiment ‘Schrödinger’s Cat’ describes a scenario where a cat is placed inside a sealed box with a mechanism that has a 50% chance of killing it (a radioactive atom, a Geiger counter, a vial of poison, and a hammer). If the radioactive atom decays, the Geiger counter detects it, triggering the hammer to break the vial and release the poison.

Until the box is opened, the cat exists in a state of uncertainty—both alive and dead at the same time. Childbirth shares a similar uncertainty. Before labour begins (when the box remains closed), birth is both a natural, physiological process and a potential medical emergency—its path uncertain until delivery unfolds.

Yet maternity care debates often reduce birth to absolutes. One side champions birth as a natural, physiological process, resisting intervention (guarding ‘normality’); the other through the lens of risk and medical oversight. Neither captures the truth: birth is not inherently safe nor dangerous—it is both, until reality declares otherwise. A system designed for just one scenario is destined to fail.

We Need Maternity Care to be Safe for All

Imagine two types of childbirth:

– Type A: A straightforward, physiological birth with no complications.

– Type B: A birth where a potentially life-threatening issue emerges.

Evidence offers key insights:

· Before labour, even with risk assessment, we cannot predict with certainty which type will occur. Risk assessment and classification into labels like “low risk” or “high risk” may reduce uncertainty, but they do not eliminate it—like Schrödinger’s Cat, both Type A and Type B coexist until the birth itself “opens the box.”

· The World Health Organisation estimates that 15% of pregnant women globally will face a serious complication requiring skilled intervention to survive or save their baby.¹

· During birth itself, 5-10% of deliveries involve potentially life-threatening conditions requiring urgent action.²

Promoting ‘Normal Birth’

Given this inherent uncertainty, safety demands a system prepared for both possibilities—not one that prioritises or promotes one type of childbirth over the other.

However, in 2005, the Royal College of Midwives (RCM) launched its ‘Campaign for Normal Birth’. Its ‘Top 10 Tips’³ urged midwives to “Wait and See,” “Justify Intervention,” and “Trust Your Intuition.”. For Type A births, this approach may support appropriate care. But for Type B, where delays can be fatal, it risks disaster. Principles for ‘safe care’ here might be “Escalate Early,” “Be Vigilant and Risk-Averse,” and “Monitor Carefully and Work as a Team.”

The consequences are not hypothetical. The 2015 Morecambe Bay Investigation⁴ found an “over-emphasis on normal childbirth” at Furness General Hospital contributed to 11 preventable baby deaths and 1 maternal death between 2004 and 2012.

Witnesses told the inquiry that “…there were a group of midwives who thought that normal childbirth was the… be all and end all… “ and that senior people working in the maternity unit “…believed that in all sincerity they were processing the agenda as dictated at the time… to uphold normality…”

The 2022 Ockenden Report into maternity services at Shrewsbury and Telford⁵ revealed similar failures, with “normal birth” ideology and a focus on reducing intervention, linked to over 200 avoidable deaths.

If you work in maternity services, ask yourself how many tragic outcomes happen because type B births are viewed through the lens of ‘optimising normality’?

Prioritising an ideal over outcomes breeds harm.

A Better Approach: Safety, Not Ideology

The RCM finally abandoned its campaign for ‘normal birth’ in 2017, but even as recently as September last year (2024), maternity services in England were continuing to place job adverts celebrating their services as ‘promoting normal birth’.

Maternity care must once and for all, reject a model of care that promotes one birth type over another. Instead, maternity services should strive to be:-

1. Flexible and Responsive – Units must support physiological labour while equipped to identify and act swiftly when complications arise.

2. Team-Based and Collaborative – Midwives and obstetricians must unite, adapting to birth’s unpredictability and working together as one team, with shared goals.

3. Free from Ideological Divides – Care should focus on safety and personalisation, not dogma.

This means recognising (and being honest with women and families) that while many births do not require intervention, some do—and we cannot predict with certainty which ones in advance.

We must abandon the notion that the purpose of maternity care is to promote one type of birth over the other, and instead strive to create a maternity system that is responsive, adaptable and safe, no matter what reality emerges. If maternity care is delivered in a way that is only safe for type A birth, the only certainly is that sooner or later, avoidable harm will repeat.

1. World Health Organization. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. 2nd ed. Geneva: WHO, 2017. ↩︎
2. Say L, Souza JP, Pattinson RC. Maternal near miss—towards a standard tool for monitoring quality of maternal health care. Lancet Glob Health 2020;8:e673-4. doi:10.1016/S2214-109X(20)30102-7 ↩︎
3. Royal College of Midwives. RCM Campaign for Normal Birth – Top 10 Tips. London: RCM, 2005 ↩︎
4. Kirkup B. The Report of the Morecambe Bay Investigation. London: The Stationery Office, 2015. ↩︎
5. Ockenden D. Final Report of the Independent Review of Maternity Services at Shrewsbury and Telford NHS Trust. London: HMSO, 2022 ↩︎

Thoughts on Maternity Safety

Last week marked the 10 year anniversary of the publication of the Morecambe Bay Investigation report and I’ve been reflecting on the state of maternity safety – in truth – feeling lots of sadness and frustration at the heartbreaking stories of harm still emerging nationwide.

When I wrote Joshua’s Story a decade ago, my hope was that in time, the events it describes would eventually become so far removed from the current reality, that no-one reading it could perceive of similar events happening today. 

Although there has been progress in the last 10 years (stillbirths and neonatal deaths have reduced), similar events sadly continue to happen and families whose lives have already been torn apart, continue to experience significant additional harm because of the way the healthcare system responds and treats them.

For what it’s worth, here are some of my thoughts on what might help turn things around:

Calls for Inquiries

Families in Leeds and beyond are campaigning for inquiries into maternity failures – they have my unwavering support. But I think we actually need even more – and that there should be an independent review process for every maternity unit where data shows outcomes significantly below par. After Mid-Staffs, Bruce Keogh led detailed reviews of 14 NHS trusts flagged as mortality outliers (HSMR), with 11 placed in special measures.

Maternity services need a similar reckoning now- a deep dive into the most troubled units (as well as looking at units that are doing well), an investigation led by a trusted, eminent figure (and supported by an expert panel). It should include external scrutiny of serious incidents, governance, engagement with families and staff, and an unbiased assessment against a robust, evidence-based framework (like THIS Institute’s ‘For Us’ framework). This should’ve happened after the Morecambe Bay report was published in 2015. It didn’t – but it should happen now.

Acting Immediately to Improve Maternity Safety

We don’t need to wait for the outcome of more inquiries to know urgent action is overdue. Some thoughts on what I think might help:

Leadership

The government should appoint a national Maternity Safety Tsar, reporting directly to the Secretary of State for Health and Social Care, tasked with tracking progress against a new maternity safety ambition. The CQC should also name a Chief Inspector for Maternity Services, backed by a dedicated specialist team within the regulator. This might help CQC rebuild the trust and credibility any effective regulator needs.

National Improvement Support

The Maternity Safety Support Programme (MSSP) needs an overhaul – properly resourced with a central team to help local services diagnose safety issues and implement proven solutions. A review of all outstanding maternity recommendations should lead to a consolidated, prioritised national action plan.

There should also be a central repository of improvement resources, tools, templates, how-to guidance etc….  Which local organisations can access. 

Review of Midwifery Education and Training

All undergraduate midwifery courses should be independently audited to ensure new midwives are taught the lessons from major safety inquiries. Harmful ideologies should be eradicated from the syllabus.

Overhaul of MNSI (Maternity and Neonatal Safety Investigations)

An independent audit of MNSI investigation quality – including family experiences – is essential. We need faster ways to share key lessons from individual cases. After an FOI request, MNSI have now committed to publish individual recommendations from its investigations on an annual basis – but there should be a much more rapid way of ensuring all maternity services can review and proactively learn lessons when things go wrong elsewhere. Thematic analysis from MNSI should shape the national maternity safety strategy, targeting the highest-risk areas.

Culture and Transparency

System-wide alignment is critical to dismantle barriers to openness. Key areas:

• Reform NMC fitness-to-practise processes to properly weigh system issues.

• Ensure trust-level ‘just culture’ policies are applied fairly.

• Align coroners’ inquiries with systems thinking and ‘just culture’ principles.

• Address litigation: long-term I believe reform should be considered, but short-term, NHS legal services must never undermine candour or transparent investigations – there should be clearer standards around this.

Accountability

We need a clearer accountability framework, ensuring all ‘reasonably practicable’ measures are in place to ensure maternity services are safe.

Individual maternity professionals should face accountability for:

• Working beyond their competence

• Incivility, unkindness, or bullying

• Poor multi-professional collaboration

• Dishonesty or cover-ups

• Racism, sexism, or discrimination

Leaders and managers should answer for:

• Ignoring known safety concerns

• Prioritising reputation over safety

• Punishing staff who raise issues

• Serious governance lapses tied to their roles

The CQC must refine its Regulation 12 framework to clarify prosecution decisions.

Beyond This

Other vital areas – staffing, recruitment, post-harm family support, tackling inequalities, antenatal education, and multi-professional training – all need attention too.

Maternity safety can’t wait another decade for change.

Keen to hear thoughts from others.

15 years ago today…

Joshua, 27th October 2008

With every birthday that passes I wonder what he would be like now? Today Joshua should be celebrating his 15^th Birthday. 15 feels like such a big year, where children change to young adults. In that other world we often dream about, I imagine myself trying to guide him towards making wiser decisions than I did at that age, and urging him not to make the same mistakes!

Although 15 years have passed, it’s still hard to accept the reality that all we will ever be able to do is imagine.

Joshua had his life taken away from him at just 9 days of age. It’s not possible to gently describe the events that led to this. 24 hours after his birth, Joshua collapsed with sepsis. He then endured 8 days of intensive care (in Manchester and later Newcastle) where he put up the strongest of fights, only to eventually bleed to death as consequence of a necrotic left lung. That description is as soft as I can make it – the reality (and the images I have etched in my memory forever) – are too distressing to share again.

All of this could and should have been avoided had Joshua received the most basic care, in line with standards and protocols that should have been routine in any maternity unit in the country. Instead, dreams, hopes and a lifetime of love were changed forever.

Joshua on 5th Nov, 2008

The guilt I feel for not doing more to challenge the answers I was given when I raised concerns about Joshua will never leave me. Although logically I know it’s an unfair burden to carry – it’s every parents duty to protect their children and a feeling of responsibility for failing to do so often lingers.

The lead up to Joshua’s birthday is always tough – perhaps more tough than it should be – maybe I’ve not been as good at ‘moving forward’ as I could have been – but however hard I try not to think about it, the change in the weather, the autumn hues, Halloween and the build-up to Bonfire night (the day Joshua died) always evoke memories and feelings that I can’t seem to evade.

In previous years I’ve tried to mark the occasion with positive messages and thoughts – the kindness Joshua has bought into our lives and, hopefully, the difference his short life has made has been a source of comfort. But this year it’s hard to take consolation from looking there. Put simply, it feels right now that progress in maternity safety has stalled and worse still, that in some areas we are now at risk of heading backwards.

So where are we now?

The latest ‘State of Care’ report from the Care Quality Commission (CQC), published just last week paints a worsening picture of maternity services with the number of units with an overall rating of ‘inadequate’ or ‘requires improvement’ now standing at 49% – up from 39% the year before. Look specifically at CQC’s ratings for ‘safety’ and the picture is even more concerning, with 65% of maternity services falling below ‘good’.

CQC’s ‘State of Care’ Report, September 2023

The latest data from MBBRACE, looking at both maternal mortality and perinatal mortality, even when the affects the Covid pandemic are taken into account, show that progress has stalled.

Failing to learn

It’s now more than 8 years since the Morecambe Bay Investigation report was published, and since then two further major investigations reports into maternity services have been produced looking at maternity care at Shrewsbury and Telford and East Kent – these reports span different timescales and services, but the fundamental issues identified are no different. There is now another major inquiry into maternity care at Nottingham, which is now also the subject of a formal police investigation. Bereaved parents are calling for a new inquiry into maternity services at Leicester too.

Inequalities

As of 2023, the disparity in outcomes within our maternity services is stark. Statistical data reveals that the likelihood of adverse outcomes is significantly influenced by skin colour.

Black infants face over twice the risk of stillbirth compared to their white counterparts, while babies born to Asian mothers carry a risk 1.5 times higher. These disparities become even more stark when examining maternal mortality, with Black mothers being four times more likely die than their white counterparts, and Asian mothers experiencing twice the risk.

The cost of harm

The latest figures from NHS Resolution show that in 2022/23, the total projected ‘cost of harm’ for maternity incidents (the present value of the estimated costs of claims expected to be received) was £4.2 billion. That’s £133 a second. The human cost in lives forever changed cannot be measured.

Whilst new investment announced to help improve maternity safety is welcome, there surely needs to be stronger link between the cost of harm and the investment in safety improvement and prevention.

Not a week goes by without a tragic story being reported in the news – each time with the same promise that ‘lessons will be learned’, yet the stories I hear from so many families today often have similar features as our experience in losing Joshua 15 years ago.

It is important to acknowledge the positive progress that has been made in recent years. In the work I do, I’m only too aware of how hard many people, including midwives, doctors and other front line professionals, are working to deliver the very best care they can. But a clear consensus of opinion is emerging that more needs to be done to support them.

We now have a good understanding of what safe maternity care looks like, yet the same problems continue to emerge – with issues around culture, interprofessional tribalism, leadership, inequality, service structures, education and training, accountability, and governance seen time and time again.

Good people have been working hard to push for change, but it would be naïve to sit back and assume that the latest set of recommendations from the last inquiry (however well thought-out and implemented) will be sufficient. It’s time we recognised that a different approach is needed.

The first step must be acceptance that the problems we are seeing are not limited to isolated ‘unit level’ issues but rather reflect systemic problems that exist across the maternity system as a whole. Once we accept this as a starting point, it’s clear that future inquiries at an individual service level will only ever get us so far – no matter how many we have.

For these reasons, next week I’ll be adding my voice to those of other families affected by failures in maternity care, to call for a national inquiry into maternity safety.

Such a process could look beyond individual services and look holistically at the whole system, it could examine the impact of previous inquiry recommendations (those that have resulted in positive change and those that have been less successful), it could look at international examples of safer maternity systems and what we could learn from them, and it could help identity and better understand the barriers to progress and how they might be overcome.

The urgency of this cannot be overstated – it calls for a collective effort involving women, families, maternity professionals, academics, policymakers, and politicians to collaborate in understanding the barriers that have held us back and the necessary changes required to set us on a better path.

We all want the same thing; maternity professionals able to deliver safe, compassionate and personal care in a system that supports them to do so and fewer shattered lives, broken dreams and imaginary futures.

Baby Joshua – 27th October – 5th November 2008 ‘Always loved – never forgotten’