The Ockenden Maternity Review, published today, finds the NHS is not to be trusted – not for maternity care, possibly not at all. Set up in 2022 in response to concerns over the safety and competence of maternity care at Nottingham University Hospitals NHS Trust (NUH), the report finds failures of leadership, governance, and culture:

Poor practice is not investigated; learning is not integrated; and mothers and babies are failed by an organisation they should be able to rely upon.

Perfection is not to be found and should not be expected. My son’s arrival into the world was delayed by a junior doctor’s dishonest laziness. Spotting problems, she prevaricated, arranging unnecessary tests that delayed decision-making until her shift finished. Her replacement acted immediately, saving the lives of mother and baby, but at considerable cost to both.

Donna Ockenden confirms what many other reports have said before: maternity care in Britain is awful. Not all of it, but far too much, and consistently. And the poor standards survive report after report. They are undiminished by managers and politicians vowing to learn lessons. Solely at NUH, says the BBC, Ockenden identified 155 babies who died and another 105 seriously injured, who might have lived and flourished with better care.