At the heart of the trust’s problems, it seems, is a dysfunctional culture that stretches back almost a decade. In 2015, a review of its maternity services by the Royal College of Obstetricians and Gynaecologists found multiple problems, including consultants failing to carry out ward rounds, assess women or attend out-of-hours calls. The report was dismissed as “a load of rubbish” by the trust. A Maternity Improvement Plan, overseen by NHS England, was devised. However, by the end of 2019 fewer than a quarter of its action points had been completed.