The Ombudsman investigated three cases in which local statutory supervision of midwives failed, all of which occurred at Morecambe Bay NHS Foundation Trust. The cases clearly illuminate a potential muddling of the supervisory and regulatory role of supervisors of midwives. The current arrangements do not always allow information about poor care to be escalated effectively into hospital clinical governance or the regulatory system. This means the current system operates in a way that risks failure to learn from mistakes, which cannot be in the interests of the safety of mothers and babies and must change. Working with the Nursing and Midwifery Council (NMC), the Professional Standards Authority for Health and Social Care, NHS England and the Department of Health, the Ombusdman has identified two key principles that will form the basis of proposals to change the system of midwifery regulation: that midwifery supervision and regulation should be separated; that the NMC should be in direct control of regulatory activity. The Department of Health should convey these recommendations to its counterparts in Northern Ireland, Scotland and Wales and develop proposals to put these principles into effect.