Victims of NHS maternity failings across England received “unacceptable care” that led to “tragic consequences”, according to Valerie Amos, head of the national maternity and neonatal investigation (NMNI). Her early findings warn that avoidable harm and preventable baby deaths are still occurring despite years of national reviews.
Amos said essential improvements within maternity services have been “far too slow”. She revealed that the NHS has logged 748 recommendations on maternity and neonatal safety over the past decade, calling the number “staggering” and questioning why these lessons have not translated into safer care.
Recurring Failures
The investigation repeatedly heard that women were not listened to, were denied the information needed to make informed decisions, and faced discrimination — particularly women of colour, working-class families, younger mothers and women with mental health challenges. Cases included mothers who lost babies being placed on wards with newborns and ignored warnings about reduced foetal movement.
Lack of Empathy
Families also reported insensitive responses from clinical teams after tragic outcomes, leaving many women feeling blamed for circumstances far beyond their control. Amos wrote that she expected distressing stories, but “nothing prepared me for the scale of unacceptable care” affecting families across England.
National Concern
Amos questioned why England still struggles to provide reliable and consistent maternity and neonatal care nationwide. She stressed that meaningful reform is possible and urgently needed, especially as similar failings continue to appear across multiple NHS trusts.
Health secretary Wes Streeting said the update shows that “too many families have been let down”, praising bereaved parents for their courage in coming forward. He confirmed plans for a national maternity and neonatal taskforce starting next year, which he will chair.
Duncan Burton, England’s chief nursing officer, said the investigation is essential for driving change. He acknowledged that while maternity teams are dedicated, the NHS must do more to ensure safe and compassionate care for every mother and baby.
Longstanding Problems
Campaigners note that recent findings mirror failures seen in long-running scandals at Morecambe Bay, Shrewsbury and Telford, Nottingham and East Kent. Angela McConville of the National Childbirth Trust said inconsistencies in care remain “unacceptable”, especially given how many recommendations have gone unimplemented.
The NMNI will examine 12 NHS trusts, with its final report due in 2026. Amos said she is confident the investigation will finish on time and deliver the fundamental reforms needed to prevent further tragedies.
