Investigations following these and other tragedies revealed a range of problems including poor collaboration between clinicians, weak leadership, a lack of openness and inability to learn from mistakes, inadequate staffing, and bad practice including a lack of monitoring. Yet despite long lists of recommendations, and some improvements including in the use of data, it is impossible to be confident that past mistakes could not be repeated. Two years ago the Care Quality Commission rated two-thirds of maternity units inadequate or requiring improvement. Last year, the first parliamentary report about birth trauma suffered by women concluded that “poor care is all‑too-frequently tolerated as normal, and women are treated as an inconvenience”.