Where Are The Teeth? Accountability Without Enforcement In NHS Maternity Care

The publication of Baroness Amos’s final report, alongside the announcement of a national Maternity and Neonatal Commissioner, raises a fundamental question that has underpinned many previous inquiries.

Where, in practical terms, does the power to enforce actual change reside?

There is no shortage of scrutiny in the NHS. Maternity services are subject to multiple layers of oversight from regulators, commissioners, and national bodies. Reports are detailed, evidence is extensive, and recurring patterns of failure have been identified time and time again. Yet the persistence of avoidable harm points to a system that is often better at diagnosing problems than delivering the changes need to resolve them.

The challenge is not the absence of authority. It is the way that authority is distributed, coordinated and applied.

A System with Multiple Powers

Across the maternity landscape, substantial formal powers already exist.

Integrated Care Boards and NHS England hold performance management responsibilities and can place trusts under enhanced oversight. The Care Quality Commission can inspect services, issue ratings, and take enforcement action. Professional regulators can investigate and discipline clinicians. Ministers retain ultimate responsibility for funding and policy direction, while courts and coroners’ inquests provide mechanisms for accountability after harm has occurred.

Taken individually, these mechanisms are significant. They can expose shortcomings, drive improvement and in some circumstances, compel action.

However, they do not operate as a unified system of enforcement.

Fragmentation and Diffusion of Responsibility

The central difficulty is structural. Responsibility for maternity safety is dispersed across multiple organisations, each with a distinct and limited role.

One body inspects, another manages performance, another investigates serious incidents, and others regulate professional conduct. Although these functions are individually important, no single organisation both identifies system-wide failure and possesses the clear authority to compel a remedy.

In this environment, accountability becomes diffused. When problems are identified, responsibility for acting on them is shared and, as a result, often unclear. Escalation depends on cooperation between multiple bodies rather than driven by a single point of authority.

This fragmentation has been highlighted repeatedly across inquiries. It contributes to delays, inconsistent responses, and a lack of decisive intervention, even where risks are well understood and the need for action is clear.

Slow Processes and Limited Consequences

Even where powers exist, they are typically exercised through processes that are necessarily cautious and procedural.

Regulatory action follows inspections, formal notices, and opportunities for response. Performance management operates through staged escalation, while litigation and inquests can take years to conclude. By the time findings are reached, opportunities for early intervention may have beer lost.

The system also provides few automatic consequences. There are limited circumstances in which specific thresholds trigger immediate intervention. Instead, decisions often remain discretionary, shaped by professional judgement, organisational capacity and competing priorities.

This result is a landscape in which concerns may be recognised but not addressed with sufficient speed or consistency.

The Limits of the Commissioner Role

Against this background, the introduction of a Maternity and Neonatal Commissioner is intended to provide greater national leadership and coherence.

The role has the potential to improve visibility, bring together evidence from across the system and maintain focus on maternity safety at a national level. It may also strengthen the position of families seeking transparency, accountability and a clearer route through complex institutional structures.

However, the commissioner does not hold the core enforcement powers within the system. It cannot require trusts to implement changes, impose sanctions, or directly intervene in service delivery. Those responsibilities remain with existing regulatory, commissioning and oversight bodies.

As a result, its effectiveness will depend on its ability to influence those organisations that do possess operational and regulatory authority. Any impact is therefore likely to be indirect, relying on scrutiny, persuasion and political support rather than formal powers of control.

Alignment Rather Than Addition

The risk is that the commissioner becomes an additional layer within an already complex framework of oversight.

That risk is not simply one of duplication. It reflects a deeper issue concerning how the system translates findings into action. Without clearer alignment between those who identify problems and those with the authority to enforce solutions, additional scrutiny does not necessarily lead to improved outcomes.

The recurring theme across maternity inquiries is not a lack of understanding. The causes of failure have been examined extensively and are often well understood. The challenge lies in translating that understanding into timely, consistent, system-wide change.

A Question of Implementation

For legal practitioners, these structural features are familiar. Many clinical negligence claims arise in circumstances where risks were known but not adequately addressed, where warning signs were present but not acted upon, and where opportunities for learning were missed following previous incidents.

These patterns suggest that harm is often rooted, not in isolated error, but in wider systemic design.

The challenge, therefore, is not simply to generate further recommendations, but to ensure that existing powers are exercised effectively and in a timely manner. That may require clearer lines of accountability, more robust triggers for intervention, and greater willingness to act when standards are not met.

Conclusion

The NHS maternity system is not lacking in regulatory or managerial authority. Rather, it contains multiple sources of power, each with defined responsibilities.

The difficulty lies in how those powers are coordinated and in the absence of a single mechanism that both identifies failure and ensures corrective action is taken

In that context, the appointment of a Maternity and Neonatal Commissioner may improve focus, visibility and coherence across the system. However, it does not, in itself, resolve the underlying issue of enforcement.

Until that gap is addressed, there remains a risk that findings continue to be repeated, recommendations continue to be made, and meaningful change will remain uneven and slow to materialise.