We must appoint a maternity commissioner, or risk the deaths of hundreds more mothers and babies

My heart went out to the brave, dignified and grieving families who gathered last week to hear Donna Ockenden’s report about what happened to them, their babies and loved ones at two Nottingham maternity units.

They were not failed by Ockenden’s comprehensive and often distressing review detailing years of poor training, poor culture, incompetence, bullying and coverups.

She found more than 500 mothers and babies came to harm or died as a result of inadequate care at these two units. An avoidable tragedy that should make the entire country angry.

I watched them silently weeping as they listened, and I knew we should be looking at a new dawn, a sea change in how we care for mums and babies. However, I fear it will not happen unless the government appoints an independent, nonpolitical maternity commissioner to oversee the change we need to end this national scandal.

I say this because we have sadly been here before in other reviews and investigations, from Morecambe Bay and Kent, to Telford and now Nottingham, spelling out the same terrible care, death and, at times, cruelty. Before Nottingham, there were almost 750 existing recommendations from these reports to improve maternity services. Few are implemented in any cogent way because of a lack of expert leadership, while women and babies continue to be harmed or die.

It’s almost impossible to comprehend, especially when, staggeringly, maternity negligence liabilities in England from 2019 to 2025 reached £27.4bn – more than the £18bn budget allocated to maternity care over the same period.

My 2024 cross-party parliamentary report on birth trauma – driven by my own experience of poor care while giving birth to my daughter – detailed the same themes as other reports: a postcode lottery of care and scant regard for women injured mentally and physically by giving birth. No wonder the negligence bill is so high. The report published by myself and Rosie Duffield MP also recommended a maternity commissioner.

The new health secretary – in the job for a matter of weeks, but perhaps not in a few weeks’ time – promised little to address failings on the back of Ockenden’s report, only an action plan in six months, even though Ockenden herself pleaded for the government to act now.

But there is still time to do good. This week , Valerie Amos’s national maternity and neonatal report is due to be published. She must recommend a maternity commissioner. The rationale is simple and persuasive: there is presently no one and no one mechanism to ensure any recommendation or plan is implemented.

And who must that person be? In my view, it must be Ockenden. There is no other figure in public life with the expertise and trust.

She would drive a national maternity improvement strategy. She would protect, champion and listen to mums by implementing long-term plans to drive improvements in maternity services.

In Ockenden, we would, crucially, have someone for the first time who is able to see what the priorities are from those hundreds of recommendations to keep mums and babies safe.

A commissioner is not a radical development either. We already have a children’s commissioner for England and a domestic abuse commissioner for England and Wales.

Both expertly lead on difficult and complex subjects, and drive change in areas just as important as maternity. It is utterly bewildering that we do not have one for mums and babies.

My own experience of birth trauma, of a third-degree tear and of being operated on awake while doctors tried to stop the bleeding, is never far from my thoughts when reports such as Ockenden’s are published.

The midwife who came to me when I called for help and said: “Not my baby, not my problem” before walking off haunts me because I know it haunts so many other women who experienced similar – and I want it to change.

I understand what happened to many in Nottingham and elsewhere is far worse than I experienced, but no woman should have to suffer any of it in 21st-century Britain when a commissioner could make the difference between real progress or a trip somewhere else to hear about the next maternity scandal.

My plea then is for the government to finally act. Put in place a maternity commissioner without delay.

Theo Clarke is a former MP and chair of birth trauma inquiry. Her book Breaking the Taboo: Why We Need to Talk About Birth Trauma is published by Biteback. Order a copy from observershop.co.uk

Photograph by Christopher Furlong/Getty Images