Expert blog: Creating the conditions for safe maternity care

As the Ockenden review into maternity services at Nottingham University Hospitals NHS Trust is published this week, the focus will rightly be on the families who have campaigned for years for answers.

There is another story running alongside it though, about what happens to a workforce when its concerns go unheard for too long and experience subsequent external overlapping scrutiny when safe care fails.

What we are seeing in Nottingham, and in maternity services more widely, is not a simple story of individual failure. It is a pattern consistent with what we recognise as moral injury: the harm that occurs when staff know what good care looks like, are repeatedly prevented from delivering it, and carry that gap for years without resolution.

Moral injury in healthcare

When concerns are raised and nothing changes, the psychological cost is significant. Staff describe a creeping professional hopelessness, and in response several patterns tend to emerge. Some narrow their focus to the tasks directly in front of them, because that is the only thing left within their control.

From the outside this can look like detachment, but it is better understood as a defence against feeling the full weight of a situation they cannot change.

Others lose confidence in their own clinical judgement, escalating decisions and seeking medical review for situations they would once have managed independently, which gradually erodes the autonomy and expertise the profession depends on.

For some, the gap between what they know is right and what they are able to deliver becomes intolerable, and they leave the organisation or profession altogether.

None of this excuses poor practice where it occurs. But understanding the mechanism matters, because disciplining individuals without addressing the conditions that produced the behaviour all but guarantees it will recur, in a different unit, with different names.

The toll is not only psychological. Sustained moral distress and chronic understaffing are associated with measurable physical and mental health harms, including burnout, sleep disturbance, anxiety, and in some cases the kind of exhaustion that leads to long term sickness absence. A workforce carrying that level of strain is also a workforce at greater risk of the errors that scrutiny is designed to prevent.

Why trust breaks down in organisations

There is also a knock-on effect for the workplace itself. Unheeded concerns erode the safety mechanism organisations depend on. If staff learn that speaking up changes nothing, the next concern goes unspoken. Trust in the organisation to actually respond to concerns, rather than simply receive them, is fragile and easily lost.

Once staff stop believing their organisation will act, they either escalate everything defensively or stop raising issues altogether, both of which carry risk.

Behaviour that is repeatedly modelled by senior colleagues and never challenged can also become the unspoken norm for those learning the job.

What we are really describing is trust breaking down at three levels at once. Staff lose trust in their own clinical judgement. They lose trust in their organisation to provide the staffing, training and resourcing needed to work safely, to respond meaningfully when concerns are raised, and to back them when they have followed the evidence and an unexpected, tragic outcome occurs regardless. The public's trust in the service is shaken too.

These three are mutually reinforcing, and public confidence cannot be rebuilt while staff still doubt their own judgement or their organisation's willingness to listen and act.

The impact of overlapping investigations

Layered on top of this is a structural problem. CQC inspections, professional regulators, police investigations and public inquiries each pursue a distinct and legitimate purpose: quality, conduct, criminality, and truth telling respectively.

None of these mechanisms currently coordinate with one another, and none build in a recovery phase between rounds of scrutiny.

The result is a workforce experiencing one unbroken wave of investigation rather than several purposeful, time bound processes. This is not an argument against scrutiny. It is an argument for recognising that scrutiny alone cannot deliver recovery.

What recovery should look like

Rebuilding pride and psychological safety requires more than improved leadership messaging, although leadership that is genuinely authentic, transparent and visible matters enormously.

It requires protected, multidisciplinary reflective practice, since clinical decisions are made by teams, not individuals, and reflecting on them separately misses how those teams actually function.

It requires a workplace narrative that makes space to reconnect with the genuine privilege of the role, alongside the necessary reckoning with what went wrong.

Structurally, it also requires mandated safe staffing and continuity of carer models that allow relationships, rather than rotating shifts of strangers, to anchor the care women receive.

Public inquiries are necessary. The real test of whether this moment produces lasting change will not be visible on publication day though. It will be visible in a year, or two, in whether staff feel safe enough to speak up, trust their own judgement again, and whether public confidence genuinely returns.

Professor Gemma Stacey is Associate Dean for Practice in the School of Social Sciences at Nottingham Trent University.

Gemma is a mental health nurse, academic, and charity executive with expertise in workforce development, clinical leadership, and knowledge exchange in healthcare settings.