This article first appeared in Volume 54, Issue 1 of our print edition of Index on Censorship, titled The forgotten patients: Lost voices in the global healthcare system. Read more about the issue here. The issue was published on 11 April 2025.
In October 2022, Dr Bill Kirkup, who was responsible for undertaking investigations into maternity scandals at hospitals in the north-west and south-east of England, wrote an open letter to the UK health and social care secretary and the chief executive of the National Health Service quoting a bereaved mother: “When your baby dies, it’s like someone has shut the curtains on life, and everything moves from colour to darkness.”
Kirkup continued: “How much more difficult must it be if the death need not have happened? If similar deaths had occurred previously but had been ignored? If the circumstances of your baby’s death were not examined openly and honestly, leaving the inevitability of future recurrence hanging in the air?”
His words were meant to draw a line under the scandals, but they proved horribly prophetic. Kirkup was recently called to give evidence at the inquest into the death of Ida Lock, who was resuscitated after birth at the Royal Lancaster Infirmary in November 2019 but died a week later from brain injuries sustained during delivery due to a lack of oxygen.
The hospital, part of the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT), initially denied any failings but was ultimately forced to recognise that mistakes had yet again been made. A whistleblower came forward in February to claim that warnings had not been heeded, causing the inquest to be delayed.
The whistleblower, former inspector Ian Kemp, claimed health watchdog the Care Quality Commission (CQC) “watered down” his report after he was asked to investigate maternity care at the NHS trust following the death of baby Ida. At the time, the CQC’s lawyers told the coroner’s court the allegations were “not recognised” by the watchdog.
The five-week inquest has now finished, with coroner Dr James Adeley concluding that Ida’s death was caused by the “gross failure” of three midwives to “provide basic medical care”. In a statement, Tabetha Darmon, chief nursing officer at UHMBT, said: “Losing a child is tragic and our heartfelt condolences go out to Ida’s parents, family and loved ones. We are truly sorry for the distress we have caused. We accept that we failed Ida and her family and if we had done some things differently and sooner, Ida would still be here today.” She also apologised for “the way investigations into Ida’s death have been conducted since 2019”, adding that the trust takes the coroner’s conclusions “very seriously”, and it will “do everything [it] can to prevent this from happening to another family”.
Recent scandals that have blighted UK hospitals reveal a horrific pattern of cover-up and secrecy in the NHS. Time and time again, concerns over the treatment of the most vulnerable in society – babies and women in particular – have been silenced or ignored by senior managers and clinicians.
“A series of failures at almost every level”
The investigation into the UHMBT in 2015 found that 11 babies and one mother died at Furness General Hospital between 2004 and 2013 as a result of failures in clinical competence, poor working relationships between medical staff and a resistance to investigating serious incidents. Kirkup concluded: “Our findings are stark and catalogue a series of failures at almost every level – from the maternity unit to those responsible for regulating and monitoring the trust.”
Published seven years later in October 2022, the report of the investigation into East Kent Hospitals University NHS Foundation Trust found that 45 babies had lost their lives due to failures of teamwork, professionalism, compassion and listening, noting a resistance to listening to parents’ concerns. Kirkup wrote: “It is too late to pretend that this is just another one-off, isolated failure, a freak event that ‘will never happen again’.”
Meanwhile, an unprecedented review of cases at the Shrewsbury and Telford Hospital NHS Trust spanning two decades was also published in 2022 and found that more than 200 babies and nine mothers died unnecessarily. The chair of the review, senior midwife Donna Ockenden, said her report was “about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve, and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives”.
Speaking to Index, Ockenden said there was an immediate need for investment in perinatal services (the period of time between becoming pregnant and up to a year after giving birth) – but this is not the whole story. “There has to be an absolute commitment to listening to women, hearing women and acting on what they tell you,” she said. “It’s fair to say that for many staff in the NHS, not just maternity, they do not currently have the time to care. But there are occasions when there would be time and still women aren’t listened to.”
She is now carrying out a review into maternity services at the Nottingham University Hospitals NHS Trust, which will examine more than 2,500 cases of death or serious harm in the maternity unit over a 10-year period from 2012 to 2022. Her inquiry, which had been due to report at the end of this year, will be extended until June 2026 after 300 new cases were discovered by a coroner.
Even staff at Nottingham University Hospitals NHS Trust were not necessarily protected when they chose to have their babies delivered by their colleagues. Jack Hawkins, who worked as a doctor at the trust, and his wife Sarah, who was employed there as a senior physiotherapist, lost their daughter Harriet in 2016 when she was stillborn. The trust admitted that a series of errors by midwives and doctors had led to Harriet dying in the womb and agreed to a £2.8 million payout (roughly $3.6 million) in 2021. The couple are now at the centre of the campaign for justice for families affected by the Nottingham scandal and have called for full transparency and accountability.
Systemic issues in maternity care
The inquiries that have already published their reports identified a common set of problems with senior clinicians and hospital managers failing to listen to parents or to act when the alarm was raised by staff. We wait to see if Nottingham will be any different, though the NHS’s track record invites scepticism. This is not a historical story; it is an ongoing crisis with new details and new scandals emerging all the time.
Maxwell Mclean, the former chair of Bradford Teaching Hospitals NHS Foundation Trust, is currently pursuing an employment tribunal over unfair dismissal, claiming the trust was unhappy after he raised concerns about baby deaths in 2021. Meanwhile, a review into baby deaths at University Hospitals of Derby and Burton NHS Foundation Trust published its report in 2024, finding that national guidelines for monitoring foetal movements had not been followed and identifying “care issues” that could have contributed to loss of life in 150 cases.
Some parents want a full national inquiry into maternity services. Neil and Katie Russell, whose baby Poppy died in April 2021 at The Princess Royal Hospital in Telford, have called for a nationwide investigation and have been joined by other bereaved parents from across the country. The Russells believed the increased scrutiny on the Telford hospital would mean their baby would be safe, but she died while the Ockenden inquiry was being carried out. In 2023, a coroner ruled that Poppy’s death was preventable and said effective monitoring of her foetal heart rate had not happened.
In May 2024, the UK’s All-Party Parliamentary Group (APPG) on Birth Trauma published its report Listen to Mums: Ending the Postcode Lottery in Perinatal Care. It recommended the creation of a maternity commissioner post, who would report directly to the prime minister and develop a national maternity improvement strategy.
Four months later, the CQC reported that harm at maternity units was at risk of becoming normalised following a review of 131 units across England. The pattern of criticism was familiar: staffing shortages, problems with equipment, cramped wards, inconsistencies in reporting incidents and poor leadership and management leading to a blame culture. Mothers and babies from ethnic minority backgrounds were found to be at increased risk, with a lack of support for women whose first language was not English.
The maternity units investigated by the CQC had not been inspected since 2021. They amounted to two-thirds of the total number of units in the country – and of those, nearly half were rated inadequate or in need of improvement and 65% were judged to be failing on the single issue of safety.
Threatened for speaking out
The investigations carried out by Kirkup and Ockenden and the recent CQC review build a picture of a systemic failure in maternity services across the country. But this is often compounded by a culture of secrecy, cover-up and blame.
And this is not confined to maternity services. It is no coincidence that NHS trusts repeatedly found to be dysfunctional often have a record of silencing those trying to raise the alarm. It is helpful to look at the problems faced by the NHS as either horizontal or vertical. The horizontal problems are those facing services in particular areas of care, such as for older people, breast screening or maternity. But then there are the vertical problems faced by a specific NHS trust, where both professionals and patients claim a toxic culture runs from top to bottom.
Radiographer Sue Allison claimed she was bullied, ostracised and blocked from promotion after raising concerns in 2012 about malpractice in the breast screening unit at Royal Lancaster Infirmary (part of UHMBT) and cancer diagnoses being missed. Instead of addressing the potentially fatal consequences of failures in the hospital’s breast screening unit, Allison claims managers victimised her for blowing the whistle and eventually forced her to resign and abandon the career she loved.
Allison later successfully challenged the gagging order she had felt pressured to sign, and in 2019 health secretary Matt Hancock used her case to propose a ban on the use of non-disclosure agreements in the NHS.
Speaking at the time to The Daily Telegraph, Hancock said: “We stand with whistleblowers. Making someone choose between the job they love and speaking the truth to keep patients safe is an injustice I am determined to end.” Six years later, this ban is yet to be enforced.
Allison told Index that UHMBT later offered her an advisory job working with the director of nursing, but she turned it down because of the confidentiality clause contained in the contract. Instead, she successfully stood for election as a public governor of the trust. According to government guidance, the holder of this role “represents the public’s interests and works to ensure that an organisation meets the needs of its community”. However, Allison claims that when she and two other governors began to hold the trust to account, they were sidelined and eventually forced out.
Allison told Index: “Some trusts just have a toxic culture. After more than 30 years of service as a radiographer, I saw my career destroyed because I tried to raise the alarm about potential serious harm to women in the care of the Morecambe Bay trust.
“My subsequent attempts to hold the trust to account over the following 10 years were frustrated because the institution did not genuinely believe in transparency and was determined to protect its reputation, even to the detriment of the patients it had a duty to care for and protect.”
At the time of her resignation in 2023, UHMBT chair Mike Thomas was reported as saying: “We respect Sue’s decision to stand down as a trust governor and thank her for her contribution… during her time on our Council of Governors.” He offered Allison an exit interview to discuss further issues.
“We wish to make it clear that bullying and/or harassment has absolutely no place within our trust. All feedback and concerns are taken seriously and we actively work to improve on any issues raised,” he added.
Not all whistleblowers are staff, and Allison has supported patients putting their heads above the parapet. One of these cases is Diana Merrick, who had surgery at Westmorland General Hospital (also part of UHMBT) after treatment for breast cancer.
Merrick, an artist from Cumbria, alleges that the routine operation she was booked in for was changed to a more complex one at the last minute. Following the surgery, she developed complications and raised concerns but claims these were ignored. Five months later, she had to have an emergency operation and is now waiting for breast reconstructive surgery.
She says she was characterised as “anxious”, “demanding” and a “serial complainer”. She has complained to UHMBT, the General Medical Council (GMC) and the Parliamentary and Health Service Ombudsman.
She told Index: “If the trust continues to dismiss legitimate concerns, patient safety will suffer, and preventable deaths will continue. I initially raised concerns on the advice of a staff member, solely to help the hospital and protect others from harm. I was shocked when the hospital responded with contempt and tried to silence me.”
Index put Merrick’s claims to UHMBT but the trust was unable to respond by the time of publication for reasons of patient confidentiality.
Another case that Allison championed was that of Peter Duffy, a consultant surgeon in urology at UHMBT. In 2015, Duffy had blown the whistle to the CQC about dangerous practices within UHMBT’s urology services, which had led to 520 cases of serious harm. NHS England ended up commissioning an investigation into the department.
The trust was later forced to pay out £102,000 (roughly $132,000) in damages to Duffy for constructive dismissal. In 2023, the surgeon announced he would be leaving the medical profession entirely after 43 years of service as a result of being “hunted” out of the NHS.
Tommy Greene has tracked the whistleblowing cases at UHMBT, first as a local reporter with The Westmorland Gazette and then as a journalist with Computer Weekly, the publication which broke the story of the Post Office IT scandal.
He told Index: “A culture of secrecy and cover-up appears to have persisted at the Morecambe Bay trust well after the revelations of its historic maternity scandal came to light. There is no doubt this has contributed to the trust’s ongoing problems, which show little sign of going away.
“Over the last decade, it has become clear that similar practices to those previously uncovered at the trust’s maternity services – burying evidence of healthcare failings, poor clinical governance and reprisals against multiple whistleblowers – have led to further serious harms across several more departments, including Morecambe Bay’s breast screening, urology, and trauma and orthopaedics units.
“Disproportionate focus on reputation management – in particular, on advancing a ‘turnaround’ narrative at UHMBT – has led to avoidable suffering for patients and families, the trashing of various careers and an overall loss of public confidence in the management of local healthcare services. Far from promoting the
NHS’s stated ‘freedom to speak up’ values, these episodes are likely to have a chilling effect on workers who are keeping the service going at a time of unprecedented pressure.”
Looking to the future
The case of Lucy Letby, the nurse convicted of murdering seven babies at the Countess of Chester Hospital and attempting to kill six more, has brought whistleblowers in the NHS into sharp focus. Doubt has been cast on the safety of the convictions by an independent panel of experts put together by Letby’s solicitors. But what is not in doubt is that between June 2015 and June 2016, babies were harmed and died unnecessarily, just as they did in scandals at other hospitals around the country.
A judicial inquiry into the case is being carried out by Lady Justice Thirlwall, who will report in the autumn. The former chairman of the Countess of Chester Hospital NHS Foundation Trust, Sir Duncan Nichol, has already admitted the hospital “failed to keep babies safe in their care” and has apologised, recognising that failures caused “unimaginable grief for the families whose babies died”.
The whistleblowing charity Protect recently estimated that the cost of the Letby case, including the Thirlwall Inquiry and estimated compensation to the bereaved families, is likely to run to £40 million (roughly $50 million). In a report which also looked at the Post Office scandal and the collapse of construction company Carillion, the charity made a series of recommendations. These included placing a duty on employers to investigate whistleblowers’ concerns, increasing whistleblower protection to everyone in the workplace, addressing the consistent failures at board level and ensuring implementation of recommendations from inquiries.
The government is already looking at stronger protections for NHS whistleblowers, including proposals to ban managers who silence whistleblowers from working in the NHS and to make them accountable for responding to patient safety concerns. The recent decision to scrap NHS England could also provide an opportunity to increase transparency through organisational restructure.
It is clear that policy change would help. However, in many cases the whistleblowers leading the campaigns for justice are the bereaved parents themselves and no amount of workplace protections would ensure their voices were heard.
What frustrates campaigners is that many of the statutory frameworks are already in place. The NHS regulator, the CQC, is there to ensure individual trusts are doing their jobs. It is now 10 years since Sir Robert Francis QC published his Freedom to Speak Up review into whistleblowing in the NHS. This led to the establishment of the National Guardian’s Office and the creation of Freedom to Speak Up Guardians. There are now 1,200 guardians whose job is to encourage a culture of openness free from fear of reprisals from managers.
One paragraph in Francis’s report still stands out: “There are many reasons why people may feel reluctant to speak up in any industry. For example, they may be concerned they will be seen as disloyal, a ‘snitch’ or a troublemaker. Two particular factors stood out from the evidence we gathered: fear of the repercussions that speaking up would have for an individual and for their career; and the futility of raising a concern because nothing would be done about it.”
Beyond the questions of transparency and accountability lies the fundamental problem of resourcing – in many hospitals there are simply not enough obstetricians and midwives. The various reviews into baby deaths have also revealed a lack of specialist training and an almost cult-like obsession with “natural” childbirth.
But none of this explains the other consistent findings of these reports: the poor communication between health professionals, the failure to learn from past mistakes, and the lapses in oversight. And nothing excuses the most damning judgment that haunts each of these maternity scandals: the lack of compassion for the parents who just wanted to know why their baby had died.
