Our thoughts are with the families whose devastating experiences are at the heart of the review into the maternity services at Shrewsbury and Telford Hospital NHS Trust.

Alongside the pain of the families, the report by Donna Ockenden and her team amplifies the voices of workers who share that they were fearful of speaking up about concerns.

Dr Jayne Chidgey-Clark, National Guardian for the NHS said: “This report highlights the tragic consequences of a culture where workers are fearful of the consequences if they speak up.

“If workers feel they do not have the freedom to speak up, it is impossible to learn and improve.

“But they will not feel they can unless they are shown in practice that their voices are welcomed. This means not only for leaders to say that they are listening but to show how they are taking action as a result

“This report demands actions.

“Speaking up  saves lives if listening up and following up happens as a result.”

We welcome the Secretary of State’s commitment to implementing the recommendations in the report as a matter of urgency.

We are supporting leaders across the sector to make the changes needed and to improve their understanding of the benefits and drivers of fostering a healthy speaking up culture.

The National Guardian’s Office has worked with NHS England/Improvement who will shortly be publishing updated Freedom to Speak Up policy and guidance for leaders across the sector.

In addition, we are launching a new module as part of our Freedom to Speak Up e-learning package, in association with Health Education England – “Follow Up” – aimed at senior leaders.

The National Guardian is also part of the Maternity Culture Working Group, convened by NHS England/Improvement which is working to embed a culture of continuous improvement and learning to improve safety, quality and experience of care across perinatal services.