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Protected: To improve maternity services we must confront the damaging ideology that prizes “normal childbirth” over safe care
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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:
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.
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.
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
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.
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.
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.
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
- HSIB Expert Advisory Group Report
- Local Rationality | SKYbrary Aviation Safety
- Psychological Safety – Amy C. Edmondson
- https://www.hsj.co.uk/patient-safety/a-just-culture-for-both-staff-and-patients/7025942.article
- NHS Just Culture Guide
- NHS Improvement’s Just Culture Guide: good intentions failed by flawed design – Bill Kirkup, 2019
- Patient Safety Incident Response Framework
- Being Fair – NHS Resolution
- NHS Staff Survey
- Being Fair Tool – NHS England
- https://onlinelibrary.wiley.com/doi/full/10.1111/hex.13478
- 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.
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.
- World Health Organization. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. 2nd ed. Geneva: WHO, 2017. ↩︎
- 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 ↩︎
- Royal College of Midwives. RCM Campaign for Normal Birth – Top 10 Tips. London: RCM, 2005 ↩︎
- Kirkup B. The Report of the Morecambe Bay Investigation. London: The Stationery Office, 2015. ↩︎
- 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…
With every birthday that passes I wonder what he would be like now? Today Joshua should be celebrating his 15th 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.
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’.
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.
Making safe birth the new ‘normal’ – The urgent need to build consensus around the ‘normal birth’ debate
Introduction
In March 2015, the Morecambe Bay Investigation, chaired by Dr Bill Kirkup was published. The report concluded that a ‘lethal mix of failures’ contributed to the avoidable death of mothers and babies at Furness General Hospital (FGH) between 2004 and 2012. A major theme identified was that maternity care became “..strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care”. The report quotes one midwife who said during her evidence ‘..there were a group of midwives who thought that normal childbirth was the… be all and end all… at any cost…’.
Concerns relating to the influence this approach had on the safety of maternity care at FGH had been raised by parents long before the Kirkup report was commissioned, but the report’s publication resulted in a renewed focus on the issue and in particularly, on the Royal College of Midwives (RCM’s) ‘Campaign for Normal Birth’.
In 2017 the Times newspaper reported that the RCM would be formally ending their decade long campaign, a move that was widely welcomed, by families and charities but which also prompted a backlash from some elements of the midwifery community. Indeed, some claimed that the news reports suggesting that an ‘ideology of normal birth’ was impacting on safe maternity care were ‘…fear-mongering untruths, aimed at damaging a profession, and limiting women’s autonomy and choice’ and on occasion, bereaved parents speaking out about the issues were vilified as being ‘…on a mission to demonise all midwives…’.
The furore that followed prompted Dr Bill Kirkup to write in the Health Service Journal calling for unity, balance and clearer messages around the debate.
A focus on safer maternity care
In the years since there has been a considerable national policy focus on improving maternity safety with clear evidence emerging that in some key areas, for example stillbirths, that outcomes are improving.
However, despite some positive progress, the Care Quality Commission warned last year that maternity services stood out as:
‘…one of the core services we inspect that is not making improvements in safety fast enough’ stating that ‘…issues identified in the 2015 Kirkup report – staff not having the right skills or knowledge; poor working relationships between obstetricians, midwives and neonatologists; poor risk assessments; and failures to ensure that there is an investigation and learning from when things go wrong – are still affecting the safety of maternity care today.’
In addition, new major independent investigations into the safety of specific maternity services have since been established.
Common themes
In December last year, Donna Ockenden published an initial report into the first 250 clinical cases (from a total of 1,862) relating to poor maternity care at the Shrewsbury and Telford NHS Trust.
Giving evidence to the Health and Social Care Committee in December, Donna Ockenden stated:
“We have spoken to hundreds of women who said to us that they felt pressured to have a normal birth. My clinical team said they have seen examples, even in situations where a normal birth in their own hospital would be contraindicated, of women being pressured to have normal births… It is important to say that at that trust there was a multi-professional…focus on normal birth at pretty much any cost.”
These comments are virtually identical to those of Dr Kirkup 5 years earlier. But could it be the case that Morecambe Bay and Shrewsbury and Telford were ‘one offs’?
In September last year, Prof Ted Baker, CQC Chief Inspector of Hospitals in England was asked during a Health and Social Care Committee hearing whether campaigning around ‘normal birth’ had had consequence for maternity safety more widely:
“It has in some cases. Dr Kirkup identified it at Morecambe Bay as a big issue, and we have seen it in other maternity services. There is sometimes tension between those who are proponents of what they call normal birth and those who are proponents of a more interventionist approach…When it becomes a tension between different members of staff—someone who wants to promote a normal delivery and someone who wants to be more interventionist—it becomes a cultural issue within the team, rather than people working together to do the right thing for the woman and her baby.”
Safe maternity care – a growing consensus
The high profile of maternity safety in recent years has resulted in a welcome focus on increasing evidence and understanding of the factors that impact maternity safety and the potential solutions by the academic and research community. Themes identified include ‘…a bias against complexity…’ and a ‘…professional bias towards the normalisation of pregnancy—with potentially catastrophic consequences.’
In September last year, the THIS Institute published a new framework outlining seven features of safe maternity care, based on a large multi-site ethnographic study and stakeholder consultation. The framework provides an important opportunity to build a consensus across the wider maternity system, including ongoing national policy work and regulatory focus.
Promoting teamwork and close multi-professional working
The 2008 Kings Fund report ‘Safe Births – Everybody’s business’, explored the issues around safety culture in the labour ward:
‘One consultant obstetrician with a specific interest in safety told us that the strong emphasis on normality in maternity services and the relative rarity of adverse events made it difficult to promote a culture of safety awareness on the labour ward without being perceived as alarmist and over-medicalising.’
‘We were told that the polarised views of some sections of the midwifery and obstetric professions, and their differing emphases on promoting normality or intervention, may have exaggerated the differences between the professions. We also heard that the majority of professionals working in maternity services hold more balanced views, but that these views can be drowned out by the more vociferous minority.’
’Crucially, we were told that this debate may be distracting professionals and others from the central issue of building effective teams that can ensure safety for mothers and babies.’
Events at both Morecambe Bay and Shrewsbury and Telford demonstrate the grave consequences of promoting ‘normal birth’ to the detriment of safe care and the importance of promoting a culture that supports close multi-professional teamwork.
To their credit, the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) have now committed to speak with one voice on maternity safety, affirming a joint goal that ‘…every woman should have a good birth, with the best possible experience and outcomes for mother and her baby.’
Oral evidence provided to the Health and Social Care Select Committee’s ongoing inquiry into maternity safety in England confirmed that national organisations including the DoHSC, NHS England and the Nursing and Midwifery Council no longer use the term ‘normal birth’. Sarah-Jane Marsh, chair of the National Maternity Transformation programme described the phrase as ‘..incredibly unhelpful’, a view which it seems is shared by many women and families as well as healthcare professionals.
Ongoing contention
Despite some efforts and messaging from national organisations, wider messages that emerge from influential voices from within the maternity community in England often feel contentious and divisive.
The UK based midwifery organisation ‘All4Maternity’, have published a commentary arguing that ‘… risk-averse healthcare, and contention over the use of terms like ‘normal birth’, have contributed to a rapid reduction in the opportunities for women and childbearing people to experience normal physiological birth.’
In relation to Morecambe Bay, the article argues that…
‘…despite more than 40 recommendations that emerged from systemic failings, across all disciplines… the media chose to focus on one statement: a drive from midwives of ‘normal birth at any cost’ which led to ‘demonising the promotion of normality’.
The piece argues that
‘…public perception of … the role midwives play has been eroded consistently in the media since the Morecambe Bay report…’ and finishes with a call for midwives to ‘..step up to the challenge to be changemakers as the guardians of normal birth.’
Such messages are not only deeply hurtful to the families of mothers and babies who died in part as a consequence of the approach to normal birth identified at Morecambe Bay and elsewhere, they also promote the divisive notion that ‘normal birth’ is something that needs to be actively guarded by midwives – when the focus surely ought to be on the multi-professional team providing safe and personal care – working together in the interest of all women and babies.
Conclusions
There have now been two major maternity investigation reports in England where an inappropriate focus on promoting ‘normal birth’ has been identified clearly and unequivocally as a major factor in what happened. Separately, the language of ‘normal birth’ is now recognised as being divisive and unhelpful. Given this, there seems to be an urgent need for a clear consensus position to be agreed and published so that messages moving forward are unambiguous and clear. This must also be reinforced through obstetric and midwifery education and ongoing professional training and development.
Unless this happens, mixed messages will prevail, continuing to cause hurt to bereaved families caught up in the crossfire and more importantly, filtering through to front line maternity services and contributing to inter-disciplinary tension and poor team working. If left unchallenged, sooner or later the inevitable consequence will be yet another major catastrophe.
James Titcombe – Feb 2021
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