A letter sent by worried workers in Nottingham shows why maternity care is still so much failing

And this goes to the heart of why some families are calling for a public inquiry into maternity care in the UK. While these investigations have revealed avoidable deaths and injuries, they have seen little evidence that anyone in power has been held accountable.

People are allowed to retire or find other jobs in the NHS. The former chief executive of the Shrewsbury and Telford trust has resigned months later Special measures have been taken And he moved to another NHS role – in Nottingham.

Regulators such as the General Medical Council and the Nursing and Midwifery Council have never been held accountable for failing to step in and protect patients when families are behaving badly.

The government said it had decided that the recommendations from the Nottingham review “will not sit on the shelf”. He also promised NHS staff that those who refuse to take part in upcoming maternity assessments will be forced to give evidence or face up to two years in prison.

It was preceded by two further inquiries which may focus the minds of some executives – in Leeds and Sussex. But how can this actually work? I was told that a former leader in Nottingham spoke to the Ockendon Review but could not remember much about his time at the trust. If this law is in effect, does that count as participation in the assessment?

Each of these birth inquiries began with grieving families dragging an NHS that refused to admit its failures. The health service has struggled to adapt to the modern era, where doctors are not always well-informed and patients have the right to demand better care. Too often the NHS has given the impression that it is more interested in protecting its reputation than providing safe care.

Until there is a sustained and meaningful culture change that involves working collaboratively with patients and families, many fear that maternal and infant falls will continue.