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Following the findings of the Ockenden Review, Nottingham Trent University’s Gemma Stacey and Emma Ireton explain why recommendations without implementation do not make anyone safer.
The findings of the Ockenden Review are devastating, and the pain experienced by families must remain at the centre of every conversation about maternity care. Families are right to demand accountability and answers, and their call for a statutory public inquiry deserves to be taken seriously.
But any discussion of a further inquiry needs to start with a clear understanding of what an inquiry can and cannot deliver. It cannot, in itself, deliver change. Inquiries establish facts and make recommendations.
Meaningful change depends on how those recommendations are implemented by others. In maternity care, the challenge is not simply identifying the problems but acting on lessons that have been recognised repeatedly over many years.
Recommendations without implementation do not make anyone safer. The key failures around listening to women, staffing, leadership, culture, governance and organisational learning have been repeatedly identified at Morecambe Bay, East Kent, Shrewsbury and Telford, and now Nottingham. The Amos investigation has confirmed the same patterns across twelve trusts.
The challenge is no longer a lack of understanding about the nature of the failings. It is a lack of consistent implementation of what we already know needs to change.
A consistent pattern
A new statutory inquiry would be likely to take several years and require considerable resources. Given the number and consistency of previous reviews, it is more likely to confirm existing findings than to uncover substantial new evidence of systemic failings.
The House of Lords Statutory Inquiries Committee reported that statutory inquiries producing a final report in the previous five years had taken nearly five years on average to complete, with limited transparency around whether accepted recommendations were ever implemented.
There is also growing evidence on what prolonged scrutiny does to the people delivering care. Our recently published integrative review in the Journal of Advanced Nursing synthesised international evidence on healthcare staff working in organisations under regulatory and investigatory scrutiny.
It found a consistent pattern: compliance-driven tick-box cultures, emotional strain, diminished professional autonomy and defensive practice, particularly in resource-constrained and highly scrutinised environments. This reflects what regulatory theorists call the regulatory paradox, where mechanisms designed to enhance safety inadvertently constrain the professional discretion that safe care depends on.
Crucially, the review also found that these effects are not inherent to scrutiny itself. Where oversight is enacted through collaborative relationships, supportive communication, a culture of candour and a genuine learning orientation, staff can experience scrutiny as affirming rather than undermining. The harm lies not in accountability but in how it is designed and delivered.
Our ongoing qualitative research with maternity and neonatal professionals working under years of sustained scrutiny is deepening this picture, and the emerging findings should concern anyone responsible for clinical risk.
Clinicians describe defensive documentation displacing time with women and families, escalation driven by fear rather than clinical need, and experienced midwives seeking medical review for decisions well within their scope of practice.
Many describe losing trust in their own clinical judgement, attributing good outcomes to luck rather than competence. Some conceal their profession in social settings. Others have left, or are considering leaving, because the distance between the care they want to give and the care they can give has become too great.
The workforce implications extend beyond those currently in post. Participants in our ongoing work describe consultant-led care drifting towards consultant-delivered care, with delegation sharply curtailed and students increasingly learning through simulation rather than supervised practice.
Newly qualified midwives are entering the workforce with reduced exposure to physiological birth, requiring intensive support to develop skills their predecessors acquired as students.
If risk-averse practice becomes the only model the next generation ever sees, the effects of this period will outlast any inquiry.
None of this is an argument against accountability. Where individuals may have acted dishonestly, unlawfully or in breach of professional standards, the proper routes are professional regulation, disciplinary processes, inquests and, where the evidence warrants it, prosecution.
Serious failures must always be investigated. But there is a real risk that another lengthy, resource-intensive statutory inquiry could divert attention and resources from the urgent action needed right now, while adding a further layer of prolonged scrutiny to a workforce already showing the strain of it.
Scrutiny models
What would a better approach look like? The evidence points towards scrutiny models that balance accountability with support, recovery and genuine partnership. In practical terms, that means clarity about which requirements are truly safety-critical, streamlined documentation, and team-based reflection that converts findings into shared learning rather than individual blame.
It means proportionate, context-sensitive oversight with defined phases and endpoints, so that scrutiny functions as an intervention rather than a chronic condition. And it means involving midwives, obstetricians and neonatologists in the design of the investigatory processes they work under.
For medical leaders, the immediate priorities are clear: protect supervised delegation where it is safe and developmentally necessary, invest in psychologically informed support for staff under investigation, focus on enabling culture which supports candour and monitor the educational consequences of oversight as actively as its clinical metrics. Staff wellbeing is a patient safety issue, a conclusion the Amos investigation itself reached.
Families deserve both answers and change. The government’s commitments following Amos, including a Maternity and Neonatal Commissioner and a National Action Plan, will only deliver if they carry authority, funding, transparency and clear accountability that is underpinned by a culture of candour.
Without implementation, another inquiry alone will not deliver the safer, compassionate maternity care that women, babies and families need.
Gemma Stacey is professor of health and care system resilience at Nottingham Trent University; Emma Ireton, is associate professor in law at Nottingham Trent University.
