A review or public enquiry is a formal process that investigates serious failures in care, including avoidable deaths. It aims to find out what went wrong, why it happened, and what needs to change.

Serious failures in healthcare organisations are often followed by major reviews or public enquiries such as Mid Staffordshire, the Ockendon Report, and the COVID-19 inquiry (UK Government, 2013; Ockenden D, 2022; UK Covid-19 Enquiry, 2026).

However, some problems reoccur. These include too few staff, poor workplace culture, weak leadership, and not learning from past mistakes.

Nurses and midwives often see little real change and are left to deal with the bad reputation of their workplace.

The Nursing and Midwifery Council (NMC) Code, 'Professional standards of practice and behaviour for nurses, midwives, and nursing associates' (2018) gives clear expectations for individuals when they are asked to preserve patient safety.

The NMC Code states under 'Preserve safety' at section 19:

19.1 take measures to reduce as far as possible, the likelihood of mistakes, near misses, harm and the effect of harm if it takes place

19.2 take account of current evidence, knowledge and developments in reducing mistakes and the effect of them and the impact of human factors and system failures (see note below).

Ultimately, are enquiries supporting nurses and midwives to preserve patient safety? Or are they causing further stress to the workforce?

References

Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behaviour for nurses, midwives, and nursing associates. Available at: nmc.org.uk/standards/code/ (Accessed 7 April 2026).

Ockenden D (2022) Findings, Conclusions and Essential Actions from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust. Available at: ockendenmaternityreview.org.uk/wp-content/uploads/2022/03/FINAL_INDEPENDENT_MATERNITY_REVIEW_OF_MATERNITY_SERVICES_REPORT.pdf (Accessed 7 April 2026).

UK COVID-19 Inquiry (2026) Inquiry Module Reports. Available at: covid19.public-inquiry.uk/reports/ (Accessed 7 April 2026).

UK Government (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Available at: assets.publishing.service.gov.uk/media/5a7ba0faed915d13110607c8/0947.pdf (Accessed 7 April 2026).

Further Reading

Royal College of Nursing (2025) The RCN and the UK COVID-19 Inquiry. Available at: rcn.org.uk/Get-Help/Legal-help/COVID-19-inquiry (Accessed 7 April 2026).

Royal College of Nursing (2022) Investing in Patient Safety and Outcomes. Available at: rcn.org.uk/Professional-Development/publications/investing-in-patient-safety-and-outcomes-uk-pub-010-567 (Accessed 7 April 2026).

Royal College of Nursing (2021) RCN Nursing Workforce Standards. Available at: rcn.org.uk/Professional-Development/Nursing-Workforce-Standards (Accessed 7 April 2026).

England

Care Quality Commission (2025) Regulations for service providers and managers: Regulation 20: Duty of Candour. Available at: cqc.org.uk/guidance-regulation/providers/regulations-service-providers-and-managers/health-social-care-act/regulation-20 (Accessed 7 April 2026).

NHS England (2019) The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. Available at: england.nhs.uk/wp-content/uploads/2020/08/190708_Patient_Safety_Strategy_for_website_v4.pdf (Accessed 7 April 2026).

Northern Ireland

Renfrew M (2024) Enabling Safe Quality Midwifery Services and Care in Northern Ireland. Available at: health-ni.gov.uk/sites/default/files/publications/health/doh-midwifery-renfrew-report-oct-2024_0.pdf (Accessed 7 April 2026).

Scotland

Scottish Government (2015) Clinical and Care Governance Framework: guidance. Available at: gov.scot/publications/clinical-care-governance-framework/ (Accessed 7 April 2026).

Scottish Hospitals Inquiry (2025) Scottish Hospitals Inquiry Interim Report. Available at: hospitalsinquiry.scot/reports/scottish-hospitals-inquiry-interim-report (Accessed 7 April 2026).

Scottish Social Services Council (2024) Codes of Practice. Available at: sssc.uk.com/standards/codes-of-practice/ (Accessed 7 April 2026).

Wales

Welsh Government (2025) NHS Wales complaints and concerns: Putting Things Right. Available at: gov.wales/nhs-wales-complaints-and-concerns-putting-things-right (Accessed 7 April 2026).