The independent review conducted by governance specialist Mary Aubrey identified serious and long-standing weaknesses in clinical oversight, leadership action and accountability, and governance processes.

CDDFT chief executive Steve Russell, who took up the post in September 2025, said: ‘First and foremost, I want to say how deeply sorry we are. Reading this report and hearing the experiences of women and their families who were harmed has been profoundly upsetting. We failed to provide the standard of care our patients deserved, breached their trust, and for that, I offer my unreserved apology.'

Russell said the report was a ‘turning point' for the trust, which has begun implementing a comprehensive action plan aligned with the review's recommendations, which includes: strengthening leadership capacity and capability and improving corporate governance; improving clinical governance and listening to the voices of patients experience and communication; creating a safe and open culture where the voices of staff are heard; improving contracts management for services; and improving medical leadership and management as well as the support to consultants through job planning, appraisal and revalidation.

Recently appointed interim chair, Alison Marshall, said: ‘This is a pivotal moment for change. Our duty now is to ensure the lessons identified are turned into sustained improvement. We will continue to work openly with patients, families, communities, partners and regulators to rebuild confidence in our services.'