Wes Streeting, Secretary of State for Health and Social Care, has ordered an independent public inquiry into serious failings within maternity and neonatal services at Leeds Teaching Hospitals NHS Trust, following repeated warnings from the Care Quality Commission (CQC) and distressing accounts from families.

Recent CQC inspections found that maternity units at Leeds General Infirmary and St James’s University Hospital were “inadequate”, highlighting concerns about staffing, leadership and culture. Streeting described the Trust as “a real outlier in terms of perinatal mortality” compared to national averages. 

The inquiry will examine both current and historical cases, taking a wide-scope approach similar to the Nottingham maternity review, though its terms of reference and chair are yet to be finalised. The aim is to ensure that lessons are learned, accountability delivered and families heard. 

As a partner specialising in clinical negligence and public inquiries, I have supported families through some of the most harrowing healthcare scandals - including representing families in the Thirlwall Inquiry into failures at the Countess of Chester Hospital following the Lucy Letby case. 

The announcement of a Leeds inquiry is therefore both necessary and timely. Its value, however, will depend on how it is structured and whether it can learn from the lessons of past investigations:

Families’ Voices Must Be Central 

Public inquiries are only meaningful when they amplify the voices of those who have suffered harm. Families in Leeds have campaigned tirelessly for recognition and transparency. Their persistence has brought us to this point, and their experiences must guide the inquiry’s direction. 

Beyond Individual Mistakes 

This is not just about isolated clinical errors. It’s about systemic breakdowns, failures in leadership, governance and learning. As we saw in Shrewsbury, Telford, Nottingham and Chester, poor culture and ignored warnings can persist for years unless the system itself changes. 

Legal Implications  

For families pursuing clinical negligence claims, the inquiry will be significant. Findings about systemic failings may inform evidence on breach of duty or causation. Solicitors will need to coordinate with the inquiry process to ensure that affected families’ cases are properly represented. 

Accountability and Implementation 

Inquiries too often end with strong recommendations but weak implementation. Sir Robert Francis KC was asked to consider which recommendations from various inquiries had been implemented. He found that only around 10 per cent of any recommendations had been fully enacted a decade on. This highlights that the hard work of an inquiry must continue into implementation. Recommendations must be clearly defined, costed and monitored to allow genuine accountability and sustained progress.

Real change requires not only identifying what went wrong but ensuring those lessons are embedded across the NHS. Culture, leadership and safe staffing must be at the core of any reform. 

Lessons From the Thirlwall Inquiry 

The Thirlwall Inquiry has already shown how devastating consequences can arise when warnings are ignored and whistleblowers silenced. The parallels with Leeds are striking: both involve cultures where staff feared speaking up and families were dismissed. 

The Thirlwall Inquiry effectively demonstrated the importance of: 

• Transparency: public hearings, published transcripts and open reporting. 
• Statutory powers: enabling the inquiry to compel evidence with difficult and hard-hitting questioning.
• Empowerment and real care for the families: recognising that their testimony is critical to truth-finding. 

The Leeds inquiry must adopt these principles if it is to restore public confidence and make lasting change. 

Wider Context: National Maternity Safety

Leeds is not an isolated case. It follows a string of major maternity investigations, from the Ockenden review (Shrewsbury and Telford) to Nottingham, and now the national maternity review announced in June 2025. 

The pattern is clear: whilst each trust’s circumstances differ, recurring themes persist, including under-resourcing, toxic culture, poor governance and missed opportunities to learn. 

This national picture underscores why public inquiries like Leeds are so vital: they not only expose local failures but can drive system-wide reform if their recommendations are properly enacted. 

Key Legal Issues to Watch 

As the Leeds inquiry begins, several structural and legal issues deserve attention: 

• Terms of reference: will the inquiry have the full statutory powers of a public inquiry under the Inquiries Act 2005? Its scope and powers will determine how effective it can be. 
• Disclosure and evidence: ensuring that families and their legal representatives can access documents and contribute meaningfully. 
• Parallel investigations: managing overlap between the inquiry, clinical negligence claims and regulatory proceedings. 
• Transparency and sensitivity: families deserve an inquiry process that is open yet sensitive to their loss. 
• Implementation and oversight: there must be mechanisms to ensure that recommendations lead to measurable change, not just another lengthy report. 

A Step Forward, But the Work Starts Now 

The announcement of this inquiry is a crucial step toward truth and accountability for families affected by maternity failings in Leeds. Wes Streeting appears to be a proactive Secretary of State for Health and Social Care, and I feel hopeful that this inquiry will have the full backing of the government. 

However, as experience has shown in Thirlwall, Ockenden and other inquiries, the real test lies ahead, in how lessons are implemented and how systems are reformed to prevent future harm. 

For families, the inquiry offers a voice and the possibility of justice. For lawyers, it presents an opportunity to help ensure transparency and fair outcomes. And for the NHS, it’s an urgent call to reflect, listen and rebuild trust.