Documenting user-centered design in mHealth for older adults with low digital literacy: Towards an operational blueprint and reporting checklist documenting UCD in mHealth for older adults.

Despite significant advancements in legal and ethical frameworks surrounding patient care, maternity services in the UK remain plagued by systemic and recurring failures. These are not isolated incidents of mismanagement or individual negligence; rather, they reflect an entrenched institutional culture of paternalism, one that continues to obstruct women’s autonomy and compromise their quality of care during childbirth. This article argues that these failures must be understood not merely as instances of poor practice, but as the product of institutional cultures and structural conditions that undermine and, at times, bypass meaningful engagement with patient autonomy altogether. While maternity care is the focal case, the analysis also speaks to wider concerns about organizational culture and patient voice within the NHS. The formal appearance of informed consent frequently masks persistent patterns of institutional silencing and coercion. Women, especially those from racialized, socioeconomically disadvantaged, or otherwise marginalized backgrounds, are regularly denied meaningful agency over their own care, despite the landmark ruling, which has been widely discussed in the literature as capable of strengthening patient autonomy. Inquiries into maternity care failings demonstrate that, in many cases, clinicians and institutions fail to engage with autonomy in any meaningful sense. Even where autonomy is formally invoked, it is reduced to a narrow, procedural construct—detached from the relational and institutional conditions in which decisions are actually formed. Deep-rooted assumptions about vulnerability and competence continue to shape professional behaviour, obstructing efforts to achieve respectful, responsive, and autonomous care. While legal and ethical frameworks purport to protect patient rights, they have proven insufficiently robust to challenge or transform the institutional conditions that enable these failures. First, that the most serious failures in maternity care often reflect not the misapplication of autonomy, but its absence in practice. Second, that even where autonomy is engaged, the prevailing model is understood too narrowly to capture the relational, institutional, and power-laden realities of decision-making in maternity care. As a result, it fails to provide an adequate framework for identifying, explaining, or addressing the systemic erosion of patient agency. Through thematic analysis of key maternity inquiries—including Morecambe Bay, East Kent, Telford and Shrewsbury, Nottingham, and the ongoing Independent National Maternity Inquiry—this article demonstrates how institutional structures systematically marginalize patient voices, undermine dignity, and contribute to preventable harm. These inquiries reveal strikingly similar patterns: at Morecambe Bay, avoidable deaths were linked to a ‘lethal mix’ of poor teamwork and denial; in East Kent, families were dismissed and blamed; at Telford and Shrewsbury, hundreds of cases showed patterns of coercion and neglect; and in Nottingham, women were pressured into unsafe births. These findings point to a culture dominated by professional hierarchy and disregard for informed consent—not isolated failures, but symptoms of a systemic problem embedded in the very fabric of maternity care. The analysis draws on a combination of deductive themes derived from autonomy, consent, and paternalism scholarship (including relational and feminist critiques). The limitations of existing legal protections further compound this problem. While appeared to mark a significant shift towards recognizing patient autonomy and informed consent, the recent decision signals a worrying drift back towards clinical discretion. This jurisprudential regression—discussed in depth in Section B—is symptomatic of a wider failure: although bioethical principles—such as those of Beauchamp and Childress—have championed patient-centred care, both law and ethics often fall short in practice. They remain too abstract, inconsistent, or procedurally weak to counteract entrenched hierarchies and cultural norms that sideline patients. The procedural translation of autonomy does not directly produce the most extreme failures documented in the inquiries. However, it creates a clinical and institutional environment in which autonomy is reduced to formality, thereby normalizing practices that fall short of genuine engagement and allowing more serious disregard for patient agency to persist unchecked.