NHS maternity care ‘not working’ for women and babies, review warns

The NHS is ‘not working’ for women and babies as it unforgivably makes the same maternity mistakes, a Government-ordered investigation has warned.

Families face a ‘postcode lottery’ of care with many tragically let down in pregnancy and labour by hospitals that have failed to learn from countless reviews, it adds.

This institutional inertia combined with a widespread reluctance to admit mistakes adds to victims’ trauma and the ‘cycle must stop’, a report by Baroness Amos says.

Her team has met more than 400 family members and heard from over 8,000 people, including NHS staff, through a public call for evidence, which closes next month.

An interim report published today as part of the peer’s National Maternity and Neonatal Investigation highlights deep-rooted issues across maternity services, including ‘a lack of kindness and compassion’ and pervasive discrimination.

It adds: ‘The system is not working for women, babies and families, or for staff.

‘Time and time again, families who have engaged with the investigation say that they are doing so because they do not want the same to happen to any other family.

‘And yet they are seeing the same failures repeated.

‘It is also a source of continuing distress to families, and great frustration to staff, that the areas identified in previous reviews and investigations as requiring action do not seem to have been addressed or have only been partially addressed.’

Baroness Amos’s final recommendations to the NHS in England will be published in the spring and follow a series of high-profile maternity scandals where women and babies have needlessly died or suffered lifelong harm as a result of poor care.

In her interim report, Baroness Amos says there are six factors contributing to pressures on the maternity system, including staff shortages, capacity issues, culture and leadership, racism and discrimination, lack of accountability when things go wrong and the poor condition of NHS hospitals and buildings.

She said: ‘We have seen maternity and neonatal services trying to respond in difficult circumstances and dealing with competing pressures but too often failing to deliver the safe care that women, families and babies expect and deserve, at times with devastating consequences.’

Investigators heard repeatedly from women and families about a lack of transparency, clear communication and learning when things went wrong.

The report says: ‘We heard from many families about feeling that there had been a ‘cover up’ and defensiveness from NHS trusts, the resistance they faced from trusts when requesting their notes, and instances of medical notes being amended or redacted.’

They also heard evidence ‘from a number of families where there was ambiguity regarding whether their baby had been born alive.’

‘This ambiguity created distress and long-lasting trauma for families as they struggled to deal with the fact they were given no clear explanation for the death of their baby, precisely because their baby was deemed to be stillborn,’ it adds.

Some families said the system incentivised the recording of deaths as stillbirths, as this prevents the case from being investigated by a coroner. 

One woman reported being told she was ‘too fat to have children’ when seeking support after multiple pregnancy losses, another told how staff repeatedly called her dead baby by the wrong name and a consultant allegedly ‘barked’ at a third: ‘Well, why didn’t you come sooner? Are you stupid?’ when she delayed attending the hospital when her waters broke.

Meanwhile, there are buildings with leaking roofs and inadequate facilities, with patients describing how they were taken through a delivery suite with their dead baby, hearing other mothers in labour.

The report notes: ‘In one visit, we were informed that when an instrumental vaginal delivery was required in the delivery room, the door had to be left open to provide enough space – with a screen placed outside of the room to protect families’ privacy.

‘It is inconceivable that anyone would choose to give birth in such a manner. We have to ask ourselves how this can be regarded as acceptable in 2026?’

Capacity pressures mean antenatal appointments are often not long enough to discuss a woman’s pregnancy meaningfully, particularly for women with complex health needs.

And there can be delays ‘in providing early senior clinical review, particularly in relation to decisions about care and treatment’, the report says.

Elsewhere, it identifies a toxic attitude among some staff who refuse to obey orders – and IT issues, including incomplete patient records, with patient information and notes frequently stored on multiple systems, creating a safety risk.

Richard Kayser, a medical negligence lawyer at Irwin Mitchell – which represents hundreds of families affected by maternity care failings, said: ‘Over the past two decades we’ve seen several high-profile investigations and reports – stretching back to Morecambe Bay and Shrewsbury and Telford – make hundreds of recommendations, many of which haven’t been implemented.

‘The nation’s maternity services are now at a crossroads in terms of whether the same issues continue to be highlighted or whether decisive action is actually taken to improve care for families in future.’

Health secretary Wes Streeting thanked families who shared their ‘harrowing stories’ with the review and said he will launch a maternity and neonatal taskforce to implement Baroness Amos’s recommendations when she publishes them.

He added: ‘Baroness Amos’s report lays bare the systematic, sustained, and recurring failures in maternity and neonatal care across the country, which have left too many mothers, babies and families as victims of avoidable NHS tragedies.’