Reports showing that babies and mothers died or were harmed as a result of failures by, and sometimes heartless cruel treatment in, NHS maternity units are becoming worryingly common. Dr Bill Kirkup’s just-published 192-page exposé of an appalling catalogue of failings at East Kent NHS trust between 2009 and 2020 is the second in the last 12 months. As many as 45 babies and 23 mothers in East Kent died avoidably during that time because their care was substandard, his inquiry found. March brought Donna Ockenden’s grim findings about poor maternity care at the Shrewsbury and Telford trust. And Kirkup produced the first detailed exposition of what inadequate care of women and their offspring during childbirth looked like when in 2015 he laid bare “serious and shocking” lapses in care at Morecambe Bay trust. A fourth official inquiry, again being led by Ockenden, is under way into death, brain damage and other horrendous outcomes at the Nottingham trust. Families affected claim that, despite coroners’ findings, close scrutiny of the trust by regulators, media coverage of lapses in care and pressure for change, “babies, mothers and their families continue to be harmed”. No wonder Rob Behrens, the NHS Ombudsman, says: “The phrase ‘never again’ is starting to ring hollow.” After so many reports, all of which identified similar problems, it is necessary to ask: is NHS maternity care getting better, or at least heading in the right direction? Women already pregnant or hoping to conceive will pray that progress is happening, lessons are being learned, recommendations acted upon and the care that awaits them being made safer. Worryingly, the evidence suggests that hospitals’ ability to manage childbirth – a time of intrinsic risk to mother and baby – are not on a journey of obvious improvement. Kirkup’s latest report judged East Kent’s problems in fully staffing its maternity units in Ashford and Margate to be a factor in, but not a reason for, its “pattern of repeated poor outcomes”. The main reasons included destructive “tribal” rivalries within and between obstetricians and midwives, inexperienced staff being forced to handle complex cases, the trust’s failure to learn from patient safety incidents and staff ignoring women’s concerns, he said. The NHS-wide shortage in England of an estimated 2,000 midwives does not explain any of those terrible behaviours. But a report last week by two all-party parliamentary groups of MPs and peers, the Royal College of Midwives and baby loss charity Sands found that “staffing shortages are severe, pervasive and having a profound impact on maternity and neonatal services”. And last month NHS England had to drop a key policy to improve the safety of maternity care whereby mothers-to-be would be cared for by the same team of midwives throughout their pregnancy, labour and postnatal care. It is now on hold “until sufficient staffing levels can be met”. Even more worryingly, the Care Quality Commission and Commons health select committee warned last year that learning from maternity scandals was happening too slowly. Kirkup recognises this historic failure to push through changes advised by in-depth reviews stretching back to the Ely hospital scandal in 1967-69. His solution? Don’t make countless recommendations and instead focus on just four key areas: faster identification of inadequate maternity care, more compassionate care, better team-working and honesty when mistakes happen. It is certainly a prescription for progress. Unfortunately, history suggests that whether it banishes the dangerous culture that injures and sometimes kills babies and mothers must be in real doubt.