New Report Exposes Fundamental Failures in NHS Maternity Care

Jodi Newton

Baroness Amos’ interim report lays bare a maternity system “not working for women, babies and families.”

Last week the government-commissioned National Maternity and Neonatal Investigation, led by Baroness Valerie Amos, published its interim report on maternity care in England. The inquiry was set up to look at standards of care in 12 NHS trusts with poor safety records and draw wider lessons for maternity and neonatal services.

Investigators heard from hundreds of families and thousands of frontline staff. Their findings identify six areas where the system is falling short – staff shortages, capacity pressures, culture and leadership, racism and discrimination, the poor condition of hospitals and lack of accountability when things go wrong.

Taken together, they paint a bleak picture of NHS maternity services. s

Shocking culture of concealment

One of the most disturbing elements of the report is the evidence that some maternity units altered or falsified medical records in an apparent attempt to cover up negligence.

Families recited experiences of resistance and delay when they asked for their records. When notes were finally disclosed, they were often heavily redacted and some appeared to have been “tidied up” after the event.

Women said they felt blamed for their baby’s death. They described a reluctance from staff to admit mistakes and a lack of kindness and compassion when failures were identified. Many families were not invited to participate in internal investigations, were not told the results of those investigations, and did not receive copies of reports. They felt shut out of the process and difficulties with finding closure.

The Amos report describes this behaviour as “troubling” because it obstructs any honest investigation. For parents already coping with grief or life‑changing birth injuries, discovering that records may have been changed or withheld compounds the original failing and raises serious questions about whether lessons are being learned from avoidable harm.

‘Deeply unfair’ law around stillbirths

The investigation also heard how some baby deaths are being recorded as stillbirths to prevent investigations. At present, coroners can only investigate when a baby was born alive and then died. Stillbirths, however devastating, fall outside their jurisdiction.

Some families told the investigation that they believed their babies showed signs of life, yet were officially recorded as stillborn. One family described a baby who was resuscitated for 30 minutes before being declared dead, yet the death was still registered as a stillbirth.

Baroness Amos said bereaved parents felt the system “incentivised the recording of deaths as stillbirths” and left families “without answers” about what had happened. She signalled that she may, in her final report, recommend coroner inquests be allowed to investigate stillbirths after 24 weeks to end the current ambiguity families face.

Poorer outcomes for minority groups

Worryingly, the report records extensive evidence of racism and discrimination in maternity services and links this to worse outcomes for Black and Asian women and their babies. Examples include:

• Black babies being around twice as likely to be stillborn as white babies at national level.
• Asian women being stereotyped as “princesses” when they raised concerns or requested pain relief.
• Black women being described as having “tough skin” and therefore assumed to be able to tolerate more pain, which sometimes led to delays in pain relief or escalation of care.
• Muslim families reporting discrimination on the basis of religion and feeling unable to speak up in case it affected the care their baby received.

The review also notes discrimination against disabled women and LGBTQ+ families, and persistent inequalities for women in more deprived areas. These patterns mirror what community groups and affected families have been saying for years; that prejudice and unequal treatment are not isolated incidents but built into many women’s experience of care.

Capacity pressures ‘at every stage of the journey’

The report describes services under intense pressure at every stage of the maternity journey. Families and staff reported rushed antenatal appointments that were too short to explore risk factors or answer questions properly. In addition, there were reports of prolongedwaiting time for assessment, and delays to admission, induced labours and planned caesarean sections.

Other failings included:

• Community midwives and postnatal staff being pulled onto labour wards at short notice, just to keep them running, leaving other areas short-staffed and disrupting continuity of care.
• “Poor relationships” within maternity teams. Staff described bullying, verbal aggression and racist behaviour from senior colleagues which was not challenged by management. Junior staff said they felt unable to question decisions or escalate concerns, even when worried about a woman or baby’s condition.
• Care being delivered in “outdated and dilapidated” units. Accounts of leaking rooves, cramped wards and shared corridors contaminated with blood reveal the extent of infrastructure failings, which investigators said compromised clinical care.

A turning point for maternity safety

For us as medical negligence solicitors, one of the more frustrating aspects of the Amos interim report is how familiar we are with the issues identified via our clients’ experiences and also findings of previous investigtions. Over the past decade there have been multiple reports into maternity failures at Shrewsbury and Telford, East Kent, Nottingham, and other NHS Trusts. Together they have generated hundreds of recommendations. Many have never been implemented.

Jodi Newton, head of birth and paediatric negligence here at Osbornes Law, says, “There have been a multitude of similar investigations which have failed to deliver meaningful reform. At the same time, families have suffered avoidably poor levels of care, resulting in death and devastating birth injuries. I hope that the findings will be a first step towards transforming and restoring confidence in a broken system.”

Baroness Amos’ final recommendations to the NHS will be published in Spring. Wes Streeting, the Health Secretary, has pledged a national action plan once the final report is published, alongside additional midwifery recruitment and capital investment in unsafe estates. We hope that these commitments to change are followed up this time. Families deserve to see visible improvements in how maternity care is delivered so they can begin to regain confidence in an inconsistent system.

How can we help?

At Osbornes Law, we see first-hand the severe and lasting impact which failures in maternity and neonatal services have on the families we represent. As new action plans are developed in response to the Amos report, our commitment is to ensure that affected families are heard and their experiences fully investigated.

If you have been affected by maternity or neonatal negligence, we pride ourselves on our specialist expertise in being able to advise and guide you through the complex and daunting processes. We seek to assist our clients in seeking justice, to bring a successful claim in negligence and with the hope that their experience will feed into the wider push to improve maternity safety. Please contact us by:

• Filling in our online enquiry form; or
• Calling us on 020 7485 8811