Maternity safety: What would a trauma-informed public inquiry look like?

The publication of Donna Ockenden's final report into maternity services at Nottingham University Hospitals NHS Trust has renewed calls for a statutory public inquiry into maternity and neonatal services across England.

Published on 24 June 2026, the review involved 2,536 families, the formal review of 2,511 cases and evidence from 838 current and former members of staff. Some affected families have called for a national statutory inquiry, while others have expressed different views. The Secretary of State for Health and Social Care has said that no options are off the table.

Whether a further statutory inquiry is required is a matter for Government. But the debate raises a separate question: if an inquiry was established, how could it investigate rigorously while minimising the risk of retraumatising or causing further distress to affected families?

Starting with what has already been learned

The Ockenden review offers practical examples of trauma-informed engagement. Its family engagement methodology was co-designed, with a Family and Community Voices Group helping to shape how the review communicated with families. Measures included information in different languages and the 'purple envelope' approach, allowing families to identify correspondence from the review before opening it and choose a time when they felt ready to read it.

Psychological support was built into the process. All participating families were offered access to an independent support service, including a 'Wellbeing Navigator' providing a single point of contact. Support was also available to staff and review team members exposed to repeated accounts of traumatic experiences.

A trauma-informed process is not simply about the language used in hearings. It begins with how people are contacted, how evidence is requested, how often they are asked to recount what happened, what support is available, and how much control they have over their participation.

Trauma-informed, but still fair: The difference between a statutory inquiry and a clinical review

A statutory inquiry has a different function from an independent clinical review. If established under the Inquiries Act 2005, it would have formal evidence-gathering powers, could compel witnesses and documents, hold public hearings and make findings and recommendations.

That formality does not prevent trauma-informed practice. But a trauma-informed inquiry must still be independent and fair. It cannot start from an assumption about its findings or treat evidence differently simply because an issue is particularly sensitive.

Section 17 of the Inquiries Act gives an inquiry chair considerable control over procedure while requiring the chair to act with fairness and have regard to avoiding unnecessary cost. The Inquiry Rules 2006 also protect those who may face criticism: under the Rule 13 warning-letter procedure, explicit or significant criticism cannot be included in a report without first giving the person concerned a warning and a reasonable opportunity to respond.

Trauma-informed procedure and procedural fairness are therefore not competing objectives. Families and witnesses should be treated with dignity, but individuals and organisations whose conduct may be criticised must also have a proper opportunity to understand and answer the evidence against them.

Avoiding unnecessary repetition

This may be particularly important in maternity cases. Some families have already provided detailed accounts to the Ockenden review. Others may have engaged with hospital investigations, regulators, coroners, civil proceedings or the police. Nottinghamshire Police's Operation Perth is continuing separately and is considering potential offences including corporate manslaughter, gross negligence manslaughter and serious assault.

A statutory inquiry would have its own evidential obligations and could not simply adopt the conclusions of another process without considering what evidence it needed for itself. But that does not necessarily mean beginning again every time. Where legally appropriate, earlier evidence might be used as a starting point and witness statements could build on previous accounts.

For an inquiry potentially involving large numbers of affected families, those operational decisions could significantly reduce the burden of participation without compromising the quality of the evidence gathered.

Public hearings, private information

A maternity inquiry would also have to balance transparency with privacy. Public inquiries are intended to address matters of public concern, but the evidence may contain intimate clinical information, details of pregnancy and birth, information concerning children and deceased babies, and evidence about psychological trauma.

The Inquiries Act starts from public access to proceedings and evidence, while also allowing restrictions where the statutory criteria are met. An inquiry would therefore need principled decisions about what genuinely needs to be heard or published publicly, what can be anonymised or redacted, and where restrictions are justified. That inquiry would also need to be open about those decisions, explaining clearly why they were made and engaging with those directly affected by them. Whilst some participants may never come to trust the inquiry, that process of engagement may itself help build trust and confidence in how sensitive information is handled by the inquiry.

Scope matters too

The calls following the Ockenden review have included an inquiry into maternity and neonatal services across England, rather than simply another investigation into Nottingham. If the Government chose that route, the terms of reference would need particular care.

There have already been other major maternity reviews. A new national inquiry would need to identify what it could establish that previous reviews have not. It might, for example, examine why similar concerns recur, whether recommendations have been implemented, and whether there are systemic barriers to learning.

An inquiry that simply repeats earlier investigations could increase delay, cost and the burden on families without necessarily producing better answers. Trauma-informed design and disciplined scope are therefore closely connected.

What happens next?

The Government has already announced measures following the Nottingham report, including extending Martha's Rule to maternity settings and developing a national action plan drawing together recommendations from the Ockenden review and wider maternity work. The question of a statutory inquiry remains open.

If an inquiry is ultimately established, its success will not depend only on its legal powers. Decisions made at the beginning - scope, evidence strategy, family engagement, psychological support, communication, coordination with other processes and the structure of hearings - will shape much of what follows.

A trauma-informed inquiry should not be a less rigorous inquiry. Properly designed, it should maintain rigour and fairness while reducing unnecessary harm. For an inquiry examining experiences in which many families already describe having felt unheard, that distinction would matter.

Rhys Brennan, Senior Associate, contributed to this article.

This publication is intended for general guidance and represents our understanding of the relevant law and practice as at September 2026.  For more information see our terms & conditions.