Victims of NHS maternity failings received “unacceptable care”, leading to “tragic consequences”, the head of an investigation into maternity care in England has said.
Changes within services have been too slow despite being necessary and urgent, according to a report by Valerie Amos, who is leading the national maternity and neonatal investigation (NMNI).
The document shares her initial impressions after visiting seven trusts, talking with families and meeting NHS staff.
Lady Amos wrote: “I expected to hear experiences from families about where they had been let down by the care they had received in maternity and neonatal units across the country, but nothing prepared me for the scale of unacceptable care that women and families have received, and continue to receive, the tragic consequences for their babies, and the impact on their mental, physical and emotional wellbeing.”
The report shows that the NHS has recorded 748 recommendations relating to maternity and neonatal care in the past decade. Amos described this as “staggering”.
She said: “This naturally raises an important question: with so many thorough and far-reaching reviews already completed, why are we in England still struggling to provide safe, reliable maternity and neonatal care everywhere in the country?”
The report highlights a number of issues that Amos said she had “heard about consistently”. These include women not being listened to, not being given the right information to make informed choices about their care, and discrimination against women of colour, working-class women, younger parents and women with mental health problems.
The investigation also heard of cases of women who had lost babies being placed on wards with newborns, or instances when concerns about reduced foetal movement were disregarded.
There were reports of a lack of empathy from clinical teams when things went wrong, leading to women “feeling blamed and guilty”, the report said.
Amos thanked families, some of whom have criticised the investigation and called for a statutory public inquiry and for “constructive and honest feedback” as part of the investigation.
She said: “I do not understand why change has been so slow. It is clear from what I have already seen that change is not only possible but also necessary, and it is urgent.”
The NMNI will focus on 12 NHS trusts and its findings are due to be published in 2026. Amos said she had full confidence she would complete the investigation within the timelines set out and that it would result in recommendations for “fundamental improvement”.
The health secretary, Wes Streeting, who ordered the investigation in June, said Amos’s update “demonstrates that too many families have been let down, with devastating consequences”.
He said: “Bereaved and harmed families have shown extraordinary courage in coming forward to share their experiences. What they have described is deeply distressing, and I can’t imagine how difficult it must be for them to relive these moments.
“I know that NHS staff are dedicated professionals who want the best for mothers and babies, and that the vast majority of births are safe, but the systemic failures causing preventable tragedies cannot be ignored.”
Anne Kavanagh, a medical negligence lawyer at Irwin Mitchell, which represents hundreds of families across the country affected by maternity care failings, said: “High-profile maternity scandals stretching back decades from Morecambe Bay to failings at Shrewsbury and Telford hospitals and East Kent hospital trust have all pointed to widespread and deep-rooted problems nationally.
“Today’s announcement by Baroness Amos that nearly 750 recommendations relating to maternity and neonatal care have been made, many of which over the last decade, is truly staggering.
“For a number of years we’ve maintained that many recommendations from previous reports and investigations haven’t been fully implemented, missing crucial opportunities to improve patient safety, learn from mistakes and prevent harm to patients in the first place, which is the best way to improve healthcare.
“Baroness Amos’s comments and initial findings are a sobering reminder of systemic failings and a critical opportunity to drive long-overdue improvements.”
Streeting is setting up a national maternity and neonatal taskforce in the new year, which he will chair. He said: “Harmed and bereaved families will remain at the heart of both the investigation and the response, to ensure no one has to suffer like this again. Because every single preventable tragedy is one too many.”
Duncan Burton, the chief nursing officer for England, said: “Baroness Amos’s independent investigation is a crucial step in driving meaningful change in maternity and neonatal care and we welcome her reflections and initial impressions.
“Whilst we have dedicated teams working across the country to improve services, we must do more to ensure that every woman and baby receives the safe, compassionate care they deserve. We will continue to work with colleagues across the NHS to address the issues raised.
“I want to reassure women and families that staff are continuing to work hard to provide the best possible care and want to do everything they can to support them. We would encourage them talk to their midwives and maternity teams if they have any concerns.”
Angela McConville, the chief executive of the National Childbirth Trust, said: “While some women do have safe, positive and supported experiences, the inconsistency of care is unacceptable. “None of this is new. As the report highlights, almost 750 recommendations have already been made to improve maternity and neonatal care.
“The question the investigation and the maternity taskforce must now answer is simple: why has change not happened?”
