The Ockenden Report: Why Workplace Culture Is a Patient Safety Issue

Last week the latest Ockenden Report was released. Led by senior midwife Donna Ockenden, it’s the largest review of NHS maternity services ever undertaken, examining more than 2,500 family experiences in Nottingham and asking one crucial question: how did so many people come to harm, and what needs to change?

It’s 401 pages long and it took me 12 hours solid to read. Time well spent, for someone who works in maternity improvement and who also works for an organisation with award-winning leadership and workplace culture expertise. Another collision of my worlds.

This report highlights in the starkest way possible a crucial link we’ve made over and over again. The lack of psychological safety in healthcare isn’t just about staff having a rough time, the impacts are on actual safety outcomes. Innocent people are physically harmed, they die, as a result of poor workplace culture.

That’s why our work with the NHS is some of the most important work we will ever do.

“There is increasing evidence that the culture within a perinatal service is inseparable from the quality and safety of care.”

Ockenden Report, June 2026

Whilst much of this feels affirming to us rather than revelatory, this subject richly deserves attention. Here are some of the salient points from the report, where they relate to culture, leadership and workplace wellbeing.

A Note on (Toxic) Culture

Poor behaviours become normalised when they are not confronted or challenged. This kind of culture can perpetuate through generations of leaders when they are not trained to be leaders.

A direct quote from the report states:

“There was no training for people moving into management; they just copied the poor experience they’d witnessed.”

Rapid churn exacerbates this problem. Even leaders who start full of good intentions become overwhelmed and ineffective.

An important point to make is that whilst we are often focusing on the capabilities and attitudes of individual leaders, the Ockenden Report recognises that their success depends on organisational support. People need the time, investment and conditions to lead well.

Whilst leaders set the tone, it’s clear that culture is created and sustained through the behaviours, decisions and courage of people at every level of an organisation.

What Poor Looks Like (from the Ockenden Report)

The report describes cultures characterised by:

• Invisible, unapproachable and unresponsive leadership.
• Failure to listen, with concerns ignored.
• Inability to accept challenge or criticism or recognise weaknesses.
• A lack of kindness at best and aggression and domination at worst.
• Favouritism and cliques, possibly as a survival mechanism.
• A lack of openness, trust and transparency. Mistakes are hidden.
• A lack of curiosity and challenge, leading to an unwillingness to apply learning and make positive changes.

What Good Looks Like (from the Ockenden Report)

The report also provides a clear picture of healthy organisational culture.

A healthy organisation has a “high-support, high-challenge environment”, strongly underpinned by shared values.

People feel supported and empowered, where they can speak up without fear of reprisal, and where professional development feels supportive rather than punitive.

The role of leadership in this is to “focus on enabling and expanding the conditions that allow such practice to flourish.”

Healthy cultures are led by:

• Leaders with curiosity, who seek to understand and who are open to challenge.
• A culture of accountability and learning within a psychologically safe environment where concerns are listened to and acted upon.
• Leaders who prioritise connection and positive human relationships, providing presence and guidance during difficult situations and offering wellbeing support afterwards.
• Leaders who change culture through their own actions, demonstrating compassionate leadership in their everyday behaviour.

The report concludes:

“Visible leadership is therefore not defined solely by physical presence… but by the extent to which leaders create psychological safety, support staff during periods of pressure, and ensure concerns raised by staff and families lead to action.”

This Isn’t About Happiness. It’s About Safety.

Can there be a more meaningful piece of work that proves workplace culture is not an optional concern?

This report demonstrates that when people don’t feel psychologically safe to speak up, challenge, admit mistakes or ask for help, the consequences can be catastrophic.

As Director of Happiness I’m telling you this isn’t about happiness.

It’s about safety.

The stakes could not be higher.