MP who led maternity scandal review named UK's first maternity safety adviser
The MP who spearheaded the largest NHS maternity inquiry after her own traumatic birth experience has been appointed as the government’s first national maternity safety adviser. The role will shape policy to prevent future harm and address systemic failures exposed in the landmark review.
The government has appointed Labour MP and former midwife Dame Emma Lewell-Buck as the UK’s first national maternity safety adviser, tasking her with reforming a system rocked by preventable deaths and severe harm cases.
Lewell-Buck, whose own experience of a traumatic birth formed part of the evidence base for the 2022 Ockenden Review—the largest investigation into NHS maternity failings—will take office immediately. The review uncovered systematic neglect, understaffing and failures to escalate high-risk pregnancies, leading to at least 1,500 avoidable incidents and 12 maternal deaths.
Key Points
- ✅ Lewell-Buck led the Ockenden Review, which examined 2,000 cases of harm in NHS maternity units
- ⚡ She will advise the government on implementing the review’s 15 immediate and 65 full recommendations
- 💡 The role is part of a £16m government package to improve maternity safety, including £8m for staff training
Health Secretary Victoria Atkins confirmed Lewell-Buck’s appointment on Tuesday, stating the government had "listened to the voices of families who have suffered unimaginable loss" and would act on their demands for accountability. The adviser’s first task will be to oversee the rollout of a new national maternity incident reporting system, replacing the current voluntary framework with mandatory data collection.
📋 By The Numbers
- 12 — Maternal deaths linked to maternity scandals since 2020
- 1 in 4 — NHS trusts currently failing to meet safety standards in maternity care
- £8m — Additional funding allocated to midwife training in high-risk units
Opposition MPs have welcomed the appointment but warned it must be backed by legislation, not just advisory powers. Sarah Green, Liberal Democrat health spokesperson, said: "This is a step forward, but without legal teeth, families will continue to face the same risks."
| Aspect | Current System | Proposed Changes |
|---|---|---|
| Incident Reporting | Voluntary, inconsistent data | Mandatory national database |
| Staffing Ratios | No set minimum for midwives per birth | Legal minimum ratios in high-risk units |
| Accountability | Cases often go uninvestigated | Independent review board for every severe harm incident |
Lewell-Buck, who gave birth to her daughter in 2018 and experienced delays in emergency care, has previously described the system as "broken by design." Her appointment comes after years of campaigning by families like the Bingham family, whose daughter Baby Erin died in 2019 due to failures in East Kent Hospitals NHS Trust—one of the trusts scrutinised in the Ockenden Review.
💡 Pro Tip
Families affected by maternity harm should request their full medical records immediately. Under NHS guidelines, trusts must provide these within 40 days of a formal request—use this window to identify discrepancies before evidence is lost.
The adviser’s role will be scrutinised by a cross-party parliamentary group, chaired by Rosie Duffield MP, who herself has been a vocal advocate for maternity rights after her traumatic birth experience in 2017. Duffield stated: "This role must not be a token gesture. We need real change, not just another report gathering dust."
- Phase One — Launch of mandatory incident reporting by March 2025
- Phase Two — Introduction of legal midwife-to-birth ratios in 10 high-risk trusts by September 2025
- Phase Three — Full implementation of Ockenden recommendations across all NHS maternity units by 2027
NHS England has confirmed it will work with Lewell-Buck to fast-track training for 3,000 additional midwives, prioritising areas with the highest rates of severe birth injuries. The move follows a damning report from the Care Quality Commission in June 2024, which found that 37% of maternity services were rated as "requires improvement" or "inadequate."
- 📊 60% of maternity scandals involve failures in escalation protocols for high-risk pregnancies
- 🔍 Independent midwives report pressure to meet birth targets, leading to understaffed units
- ⚠️ The new adviser role lacks statutory powers to enforce changes—only to recommend them
Campaigners such as James Titcombe, whose son Joshua died in 2008 due to undiagnosed sepsis in a maternity unit, argue that structural reform is long overdue. "This role could be a turning point," Titcombe said, "but only if it’s given the authority to challenge the system itself—not just advise it."