A new report from the national maternity and neonatal investigation (NMNI) portrays the care received by victims of NHS maternity failings in England as unacceptable, with outcomes described as tragic. The lead investigator, Valerie Amos, indicates that changes within maternity and neonatal services have been too slow even though they’re essential and urgent.
Amos shared initial impressions from visits to seven NHS trusts, conversations with families, and discussions with NHS staff. She wrote that she expected to hear about times when families felt let down, but was unprepared for the scale of unacceptable care and the ongoing harm to babies, as well as the broader toll on families’ mental, physical, and emotional well-being.
The NMNI report notes that the NHS has produced 748 recommendations relating to maternity and neonatal care over the last decade, which Amos describes as staggering. This raises a pressing question: with so many reviews already completed, why does England still struggle to deliver safe, reliable maternity and neonatal care nationwide?
Several issues recur in Amos’s observations, including women not being heard, not receiving the right information to make informed decisions, and discrimination against women of color, working-class women, younger parents, and those with mental health concerns. There are also accounts of women who had lost babies being placed on wards with newborns or situations where concerns about reduced fetal movement were ignored.
The report describes a lack of empathy from clinical teams when things go wrong, leading women to feel blamed and guilty. Amos expresses gratitude to the families who shared their experiences, even as some criticized the investigation and sought a statutory public inquiry, emphasizing the value of constructive, honest feedback.
Why change has progressed so slowly remains unclear to Amos. Her early findings indicate that change is not only possible but necessary and urgent. The NMNI will concentrate on 12 NHS trusts, with findings slated for publication in 2026. Amos is confident the investigation will meet its timelines and produce recommendations aimed at fundamental improvements.
Health Secretary Wes Streeting, who commissioned the inquiry in June, described the update as evidence that too many families were let down with devastating consequences. He commended the bravery of bereaved and harmed families who shared their experiences and acknowledged the dedication of NHS staff while underscoring that systemic failures cannot be ignored.
Anne Kavanagh, a medical negligence lawyer for Irwin Mitchell, which represents hundreds of affected families, highlighted decades of high-profile maternity scandals—from Morecambe Bay to Failings at Shrewsbury and Telford, East Kent Hospital Trust, and others—as pointing to deep-rooted nationwide problems. She called the nearly 750 recommendations astonishing and argued that many vital safety improvements have remained unimplemented for years, underscoring the opportunity to learn from past mistakes and prevent harm.
Streeting plans to establish a national maternity and neonatal taskforce in the new year, which he will chair, ensuring harmed and bereaved families remain central to the response. Duncan Burton, England’s chief nursing officer, welcomed Amos’s independent process as a crucial step toward meaningful reform and urged continued efforts to guarantee safe, compassionate care for every mother and baby. He encouraged families to raise concerns with midwives and maternity teams as improvements progress.
Angela McConville, chief executive of the National Childbirth Trust, acknowledged that while some women have positive, well-supported experiences, inconsistent care is unacceptable. She reiterated that the sheer volume of past recommendations demands answers about why tangible change has not occurred and what must happen next.
