Individuals who experience serious, life‑changing harm associated with medical care often raise concerns through the NHS complaints process and internal investigations. In many cases, they are informed that there were no errors, that care was appropriate, or that the outcome could not have been avoided.

However, when these same cases are subsequently subject to independent review, including through the legal process, different findings can emerge. Independent experts may identify shortcomings in care, errors may be acknowledged, and harm may be found to have been avoidable. By that stage, patients and families have often already been through a prolonged and demanding process in seeking clarity about what happened.

A pattern reflected in recent inquiries

These concerns are not isolated. They are reflected in the findings of two significant public inquiries published this month: the Ockenden Review into maternity care at Nottingham University Hospitals NHS Trust and the Muckamore Abbey Hospital Inquiry.

The Ockenden Review, the largest maternity review in NHS history, examined the care of approximately 2,500 mothers and babies between 2012 and 2025. It highlights accounts from families who raised concerns about their care but did not receive satisfactory answers until much later, often after serious harm had occurred.

One mother, Sarah Andrews, whose daughter Wynter died in 2019, described an experience that resonates with many families:

“We should have never had to fight in the first place… There should be accountability, and it shouldn’t be on families to have to fight to be heard and believed.”

The Muckamore Abbey Hospital Inquiry identified significant failings, including the abuse and bullying of vulnerable patients by staff. It also found that oversight mechanisms, including external inspections, were insufficient to detect or prevent these issues.

The role of organisational responses

Both inquiries highlight not only failures in care but also challenges in how concerns are addressed once they are raised. In some instances, responses from organisations have been characterised as defensive or adversarial.

The Muckamore Inquiry noted an “adversarial and oppositional approach” in parts of the Trust’s response, including communications described as confrontational. It also identified that insufficient weight was given to the accounts of patients and families when compared with contemporaneous medical records.

This reflects a broader issue observed in some cases, where internal investigations rely heavily on clinical records. While these records are an important source of evidence, they may not always provide a complete account of events. Patients’ and families’ perspectives can therefore play a critical role in understanding what occurred.

Outcomes of complaints and subsequent investigations

It is not uncommon for patients to be advised through complaints processes that care was appropriate and that no alternative actions would have changed the outcome. In some cases, however, later independent review identifies breaches of duty and concludes that different care could have altered the outcome.

This raises important questions about how early investigations are conducted, including whether there is sufficient independence, transparency and critical analysis at the initial stage.

Impact on patients and families

The consequences of these experiences can be significant. In addition to dealing with the effects of physical injury or loss, patients and families may experience additional stress when their concerns are not fully acknowledged or explored at an early stage. This can affect confidence in the healthcare system, particularly where ongoing care is still required.

As one father involved in the Muckamore Inquiry stated:

“The people in senior positions do not recognise accountability… it's something they talk about, but they don't believe in it.”

Learning and accountability

Another issue highlighted by both inquiries is the extent to which learning is consistently embedded following identified failings. While healthcare organisations often acknowledge issues and commit to improvement, there can be limited visibility around how changes are implemented, monitored and sustained over time.

This makes it difficult to assess whether similar incidents are being prevented in practice. Strengthening transparency and accountability mechanisms may help to address this gap.

Areas for development

Taken together, the findings of these inquiries suggest several areas where further development may be beneficial:

• Greater consistency in the quality and independence of early investigations
• Increased weight given to patient and family perspectives
• A continued focus on openness and learning in organisational culture
• Clearer accountability where failings are identified
• Improved transparency in how lessons are implemented and monitored

Conclusion

Patients and families seek clear, timely and accurate explanations when concerns arise about their care. The findings of recent public inquiries indicate that, in some cases, the current processes do not consistently meet this expectation.

Addressing these issues may help to strengthen trust, support learning, and improve outcomes for patients. Independent scrutiny continues to play an important role in ensuring that concerns are fully examined and that lessons are translated into meaningful change.