Background

Maternity services across the UK are operating under unprecedented scrutiny, following more than a decade of investigations that have exposed recurring fractures in culture, governance and leadership. The first major signal of systemic failure came with the Kirkup report (2015), which revealed poor multidisciplinary working relationships and inadequate leadership oversight, leading to preventable deaths and harm. These themes resurfaced in subsequent inquiries across the four nations of the UK, suggesting that the findings were not isolated anomalies but embedded system-level issues.

Maternity investigations across England and Wales have continued to identify failures such as a lack of listening to women and families; poor multidisciplinary working; low psychological safety; failure to raise concerns and escalation; erosion of staff and public confidence; and disconnected leadership. These reports include the review of maternity services at the former Cwm Taf University Health Board (Evans et al 2019); the Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust (Independent Maternity Review 2022); the independent investigation into maternity and neonatal services in East Kent (Kirkup 2022); and the independent review into maternity services at Swansea Bay University Health Board (Maternity and Neonatal Services Review 2024). Northern Ireland’s review of maternity and neonatal services (Renfrew 2024) added further evidence, detailing unsafe working conditions, staffing shortages, inconsistent governance and a lack of visible senior leadership, prompting calls for system-wide cultural and organisational reform. Emerging themes from the England-wide Amos review (2026) reinforce these patterns despite decades of earlier recommendations. The Scottish Government established a Maternity and Neonatal Taskforce in late 2025 to address leadership fragility and cultural failings (Royal College of Midwives (RCM) 2025).