And that gets to the heart of why some families are calling for a public inquiry into maternity care in England. Despite all the avoidable deaths and harms that have been revealed by these investigations, they see scant evidence that anyone in positions of authority has been held to account.

People have been allowed to retire or found other jobs within the NHS. The former chief executive of the Shrewsbury and Telford trust left months after it was put into special measures and moved into another NHS role – in Nottingham.

Regulators like the General Medical Council and the Nursing and Midwifery Council have never been held accountable for failing to step in and protect patients when families have reported egregious conduct to them.

The government says it is determined that the recommendations from the Nottingham review will not “sit on the shelf.” It has also promised that NHS staff who refuse to engage with upcoming maternity reviews will be compelled to give evidence or face up to two years in prison.

With two further inquiries already announced – in Leeds and Sussex – that might focus the minds of some executives. But how might that work in reality? I’m told one former leader in Nottingham did speak to the Ockenden review but apparently couldn’t remember much about his time at the trust. Would that count as engaging with the review if this law were in place?

These maternity inquiries each started with grieving families having to drag a reluctant NHS into acknowledging its failures. The health service has struggled to adjust to the modern era, where a doctor doesn’t always know best and patients have a right to demand better care. Too often the NHS has given the impression that it is more interested in protecting its reputation rather than delivering safe care.

Until it embarks on a sustained and meaningful cultural shift, working cooperatively with patients and families, many fear it will continue to fail mothers and babies.