The report sets out serious and recurring safety issues, including women and families not being listened to, poor governance, concerns not being acted on and deterioration not being recognised. The report also highlights how cultural misunderstanding, mistrust and systemic barriers affected how women and families from global majority voices were heard, supported and able to advocate for safe care.
These are not isolated problems; they point to wider system pressures in clinical care, organisational culture and effective oversight. These findings echo HSSIB’s report – An exploratory review of maternity and neonatal services – which found that the maternity system is complex, governance can be fragmented and learning from incidents is not always turned into action.
It also reinforces a clear message; harm can be made worse by what happens after an incident, including how concerns are handled, how patients, families and staff are treated, communicated with, and how learning is shared and acted upon.
The report’s focus on culture is particularly important. Safe care depends on people being able to speak up and be heard. When staff are afraid to raise concerns or where concerns are dismissed, early warning signs are missed and opportunities to prevent harm are lost.
Through our work we know that strong clinical governance and effective reporting systems are essential for safe care. Where these systems are ineffective, safety concerns may not be escalated, understood or acted on in a timely way, limiting accountability and improvement.
This report is a stark reminder that patient safety must be understood at a system level. Focusing on blame will not make care safer; understanding safety risk, learning from harm and acting on that learning will.
We will continue to work with partners across healthcare to strengthen safety culture, improve investigation capability, and ensure the experiences of women and families lead to real learning and safer care.
Dr Rosie Benneyworth, Interim Chief Executive at HSSIB, said: “This report reflects what patients and families have been saying for many years: when concerns are not listened to, and when staff do not feel able to speak up, opportunities to prevent harm are missed.
“These are not isolated failures. They reflect wider safety issues that arise from how services are organised, how teams work together, and how concerns are identified and acted on.
“We need to move beyond responding to individual incidents and focus on wider system improvements that can help make care safer - by listening to families, supporting staff to raise concerns, and acting on learning.
“Our own exploratory review of maternity and neonatal services highlighted the need for stronger national structures, governance, investigation quality and professional standards as part of a wider system response.”
