Maternity and Neonatal Scandals: Lessons Learned

Jodi Newton

Will investigations into NHS maternity services lead to real change?

Over the past 15 to 20 years, NHS maternity services have come under intense scrutiny, largely driven by families who have suffered harm and demanded accountability for negligent maternal care. As a result, there have been numerous investigations, independent reviews and legal cases. But the question remains: will any of this lead to real, lasting change?

Despite public outcry and political attention, the lessons learned may not be the ones we need most.

Lucy Letby and a history of maternity scandals

Lucy Letby’s criminal case—the most high-profile example of a healthcare professional intentionally harming infants—came against a backdrop of multiple maternity scandals. These were not isolated incidents, but systemic failures, often involving missed warning signs, ignored concerns and lack of accountability.

Major investigations that made national headlines

• Mid and South Essex NHS Trust (Basildon): In 2020, a CQC report found six babies starved of oxygen, putting them at risk of brain damage. This was in addition to 27 stillbirths and 55 babies born with brain damage or cerebral palsy—figures linked to the previously merged Basildon Trust.
• Nottingham University Hospitals: Between 2010 and 2020, an investigation found 46 babies suffered brain damage, 19 were stillborn, and 15 mothers or babies died due to care failings.
• Shrewsbury and Telford Hospital Trust: The Ockenden Review uncovered 201 baby deaths, 94 brain injuries and nine maternal deaths over two decades—again, due to avoidable mistakes.

Other hospitals also reported serious failings, including East Kent Hospitals, Queen Elizabeth The Queen Mother Hospital in Margate, William Harvey Hospital in Ashford, and the Countess of Chester Hospital, where Letby was employed.

The root of the problem: Toxic culture

Investigations have consistently found that a toxic culture contributed to sub-standard clinical care. Issues included poor teamwork, inadequate staffing and a failure to listen to frontline staff and families.

• At Basildon Hospital, midwife-doctor relationships were described as “dysfunctional.”
• In Nottingham, a former senior midwife reported a “culture of fear,” where staffing concerns were ignored.
• At East Kent, critical care was deemed “suboptimal,” with a culture described by one external assessor as “the worst I’ve ever seen.”

Reports highlighted widespread denial, minimisation of problems, and a failure to refer deaths or complications for investigation.

Are recommendations being ignored?

Most inquiries conclude with sensible, if broad, recommendations—safe staffing, better training, learning from mistakes, and listening to families. These goals, echoed in the Ockenden Report’s four pillars of improvement, sound reasonable. But they are often too vague to measure, making it difficult to assess whether progress is being made.

Without clear accountability and investment from government, these recommendations risk being treated as optional.

Reactionary change: Reassuring after the fact

Facing public pressure, some NHS Trusts are beginning to take action—but often only after scrutiny or intervention. For example, following a recent CQC downgrade, the University Hospitals of Leicester released an open letter reassuring patients that improvements were underway: increased staffing, new equipment and daily safety checks. But this raises a troubling question: why did it take a CQC downgrade to act?

A pattern of repetition

The investigations continue, but so do the failings. Why? Because the underlying causes are already known—and so are the solutions. What’s missing is the political will, resources, and long-term commitment to implement them properly.

Dysfunctional maternity services are not isolated failings—they’re symptoms of deeper systemic problems within the NHS.

Whistleblowers and the cost of speaking up

Historically, it has fallen to whistleblowers to flag unsafe practices. But many of them are ignored—or worse, silenced. In the Letby case, Dr Stephen Brearey raised concerns early on, but was dismissed. He now believes more babies might have survived if his warnings had been taken seriously.

If even suspicions of infant murder do not spark immediate action, what hope is there for addressing negligence?

The real lesson

Until the NHS is permanently transformed—with transparent systems, cultural reform and political backing—internal and external whistleblowers will remain the final safety net. That is not a sustainable or acceptable model for safeguarding patients.

Stephanie Prior and Josie Robinson speak to Times Radio

Stephanie Prior spoke with Times Radio about the civil claims that may follow the Letby case. Josie Robinson also contributed expert commentary to Times Radio.

Both emphasised that while no amount of money can compensate for the loss of a child, civil claims allow families to pursue justice, accountability and acknowledgement of failings. This, in turn, supports the long-term goal of reducing future harm.

How We Can Help

If a child has been injured due to medical negligence, they have until their 21st birthday to bring a legal claim. Even if the harm occurred during birth, parents and children may still have time to act. At Osbornes Law, our dedicated team is here to help families affected by maternity errors. If you believe mistakes were made in your care, we are available to explore the matter of accountability with you.

To speak with one of our solicitors, contact us by:

• Filling in our online enquiry form; or
• Calling us on 020 7485 8811

Related reading

• Damning report highlights key failings in maternity care across England