Amos and Ockenden Reviews

Introduction

Maternity and neonatal services are among the NHS’s most complex, high-risk environments. Decisions made under pressure can change lives permanently. When harm occurs, openness cannot undo tragedy, but it prevents the further damage caused by silence, defensiveness, or delay. As the Ockenden Review observed, families need truth, accountability, and meaningful learning that is acted upon.

Opaqueness and closed cultures compound trauma and destroy trust. The Amos and Ockenden reviews expose a stark failure of transparency. Our central argument is simple: this failure starts inside the workforce. We are all responsible for creating the culture in which we work – and open cultures are far, far safer. If colleagues cannot speak, listen, challenge, and learn openly with each other, they cannot offer openness to the families they serve.

However, a culture of openness and positive everyday dialogue cannot be sustained by frontline goodwill alone. We all have the ability to make a difference, but that difference is only realized when speaking up is met by colleagues who listen and take tangible, visible action.
It is clear that, for too long, the response to systemic failure has been a cycle of never-ending promises of “lessons being learned” backed up by urgent reports, dozens more recommendations being added to the pile, and superficial action plans that get shelved next to countless others.