- 24 June 2026
Responding to the publication of the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust, led by Donna Ockenden, the Chartered Governance Institute UK & Ireland (CGIUKI) said the review carries lessons about board oversight, organisational culture and accountability that reach well beyond a single trust. The review is the largest of its kind in the history of the NHS, examining around 2,500 cases involving the care of mothers and babies.
Linda Ford, CGIUKI Chief Executive, said:
“Today belongs to the families. The experiences set out in this review, and the loss that so many have carried for so long, must remain at the centre of everything that follows.
“This review is essential reading for those leading public services. This review makes clear that the weaknesses it identifies are not unique to one trust. The same governance failures, assurance that is never tested, concerns that are not heard, and accountability too easily avoided, have recurred across organisations and across previous reviews. Every board has a responsibility to ask whether it would recognise them in its own organisation, and to act if it does.
“Too often, the recommendations such reviews produce are noted and then quietly set aside. Governance is what should prevent that. Tracking, assuring and reporting on whether change is genuinely delivered is the difference between a report that sits on a shelf and one that reshapes how an organisation behaves. The measure of this review will be implementation, sustained over years and owned at board level.”
Ford added:
“This review describes boards being offered reassurance in place of genuine assurance, and a reluctance to ask hard questions when it mattered most. That is a governance failure as much as a clinical one. Boards exist to test what they are told and to act when the evidence points to serious problems. Governance cannot prevent every failure, but it can ensure that concerns are heard early and that difficult issues are confronted rather than deferred.
“Where a review finds that failings were downgraded, or that families, regulators or coroners were not given the full picture, the governance failure is graver than weak oversight. A board cannot act on risks it has been prevented from seeing, and the duty of candour exists precisely so that difficult truths reach the people responsible for acting on them.
"The review's findings on inequality and discrimination are a reminder that safe care must also be equitable care. Boards are responsible for cultures in which every woman is treated with equal dignity, and for ensuring that inequity is surfaced and addressed rather than overlooked.
"We will now see how those charged with governance across the NHS respond. What is said today will only count if it leads to lasting change."