Over the past few weeks, two major reports on maternity care in England have been published. They’re both harrowing reminders that health systems function to the effect of those governing and operating them.
The Ockenden Review into Nottingham University Hospitals exposed heartbreaking failures in care, communication, risk recognition and governance. It documented avoidable harm to nearly 2,500 women and babies that should never have occurred.
Then came the National Maternity and Neonatal Investigation led by Baroness Valerie Amos, a national review established to uncover why these tragedies continue to happen despite years of inquiries, recommendations and public scrutiny.
As someone deeply passionate about healthcare innovation since the start of my career, both reports reinforce some essential points.
We have confused reports with reform
We need to build health systems that remain resilient in the face of insufficient or inadequate governance and controls. When the system itself is vulnerable, it is not fit to deliver the quality of care it should, under the proper conditions.
The National Investigation concludes that maternity services remain fragmented, overly complex and too slow to learn, arguing that the system is not designed to deliver consistently safe, equitable and compassionate care.
Healthcare has become exceptionally good at investigating adverse events. We commission inquiries, publish recommendations, establish taskforces and produce action plans, yet families continue to tell remarkably similar stories.
Women describe raising concerns that were dismissed.
Clinicians describe systems that make safe care harder to deliver.
Organisations promise to improve from these learnings.
If the conditions that allow recommendations to translate into everyday clinical practice don't exist, reports will only serve as literature.
The recurring theme is poor risk recognition
Reading both reports, a pattern that appears again and again is missed opportunities.
The Ockenden Review identified the multiplicity of variation in risk assessment, surveillance, documentation, communication and escalation, resulting in missed opportunities for earlier intervention.
The National Investigation reinforces this. One of its central recommendations is that maternity services move away from fixed labels of "high-risk" and "low-risk" assigned early in pregnancy, instead ensuring that risk is dynamically assessed at every scheduled appointment.
Indeed, pregnancy isn't static. Risk changes, clinical circumstances change, mental health changes, social circumstances change, and information accumulates over time, requiring good data provenance practices.
Fragmentation is a patient safety issue
Perhaps the strongest message from the National Investigation is that fragmentation itself has become a source of harm.
The report describes a maternity system in which public health, primary care, mental health, antenatal, intrapartum, neonatal and postnatal services are "not joined up." Women and families repeatedly described having to recount traumatic histories to different professionals.
Information failed to follow patients across organisations, and care varied depending on geography, provider and service boundaries.
Meanwhile, staff described navigating weak digital systems, poor interoperability and fragmented governance structures that made coordinated care unnecessarily difficult.
Because of this, no single clinician necessarily sees the complete picture, and no single appointment captures the cumulative story. Instead, important signals become distributed across multiple records, multiple conversations and multiple organisations.
Listening is a clinical intervention
The National Investigation recommends treating listening to women as a critical safety issue, requiring patient feedback to become part of formal safety governance and regulatory oversight.
This is important as listening is often framed as compassion whereas the report reframes it as clinical safety.
Both reports repeatedly demonstrate that women often recognised that something was wrong before the system did. Their experiences, symptoms and intuition represented valuable clinical information.
However, workforce pressures/shortages challenge the ability to do so, consistently. One way the NHS should approach this is by investing in adaptive HIT systems that safely reduce the administrative burden on the workforce, releasing time to have extended dialogue and build trust with patients.
It’s time for real change
What stood out to me was the dire consequence of inaction. These are not the first reports into the failures of NHS maternity, yet restitutions have been immaterial in practice.
However, the forward-looking strategy set out in the National Investigation provides glimmers of hope by describing the architecture required for safer maternity care.
Principally, it calls for:
A statutory Maternity and Neonatal Commissioner that will be accountable for driving system-wide change, maternity service overhaul, championing the voices of women and families, and reporting.
A Modern Service Framework: a redesigned model of maternity triage, re-establishing workforce capacity and service commissioning.
The treatment of racism, discrimination and inequality as a critical maternity safety issue.
Investment into modern digital infrastructure that supports the quality and safety of clinical interactions.
What next
It is disappointing that in a single payer healthcare system like the NHS, innumerable variations in the way electronic records are utilised and risk assessments conducted, persist today.
It creates a disturbing spectrum of care management between women with similar risk profiles. Race and financial situation are critical factors. Women who look like me and are from similar socioeconomic backgrounds continue to take the biggest hit, weakening the very families that are merely coping, yet alone, thriving. These families should be receiving more support, not less.
At the NHS Clinical Entrepreneur Big Pitch event, this is exactly what I spoke about: the need for a complete solution that feeds disparate records into a single whole-person and cross-care risk assessment. A solution that consistently evaluates maternal risks and emerging concerns throughout pregnancy and postnatally, and provides a tool for defensible risk communication.
At Ellescope, we're building the infrastructure for continuous, data-driven risk assessment and escalation across organisational boundaries.
Read the final report and recommendations of the Independent National Maternity and Neonatal Investigation led by Baroness Amos: https://www.matneoinv.org.uk/final-reports/
Read the Ockenden Maternity Review: https://www.ockendenmaternityreview.org.uk/final-report-of-the-independent-review/
