In 2025, Wes Streeting commissioned a national maternity inquiry to try and understand why there were continued reports of avoidable deaths, injuries and poor experiences in maternity settings across the UK, despite several reviews.
Baroness Valerie Amos was in charge of the review, and her team spoke to more than 450 families, received over 10,500 responses from women and families, surveyed over 9,000 staff and visited 12 Trusts. The review has uncovered what we expected: too many women and babies are still experiencing avoidable harm, trauma, poor communication and a lack of accountability when things go wrong.
The overall conclusion of the review was that, despite many examples of dedicated staff members and excellent care, the maternity system itself is fragmented, overstretched and not consistently designed to provide safe, equitable and compassionate care.
Key Findings
There were 8 consistent themes identified by Baroness Amos from the 12 Trusts:
- Women and birthing people were not listened to: Families reported that their concerns were often dismissed, and that decisions were being made on their behalf without their involvement or choice.
- Staffing shortages: There were issues in the demand of the maternity and neonatal units being too high for the staffing levels.
- Demand exceeding capacity: As well as inadequate staffing levels, the demand itself is increasing with more complex pregnancies, and inadequate space, resources and facilities within the hospitals, leading to avoidable delays.
- Leadership and governance issues: There was often a lack of oversight from the hospitals’ boards and executives regarding their maternity services.
- Poor responses when things went wrong: Families described delays, defensiveness and inadequate apologies when failings occurred.
- Inequalities and discrimination: Systemic racism and inequalities across different ethnicities, language speakers, disabilities and areas of deprivation were consistently noted.
- Buildings and facilities were not fit for purpose: Maternity units were found to be cramped, lack privacy and often in aging and inadequate buildings.
- Poor IT systems: many Trusts had multiple IT systems that were used for different things and didn’t communicate with each other, creating safety risks and resulting in inefficient service.
Recommendations
Baroness Amos recognized the 8 themes and recommendations to improve them, such as creating a system to ensure women’s and families voices are heard, modernisation of the services, ensuring that anti-racist and anti-discrimination practices are embedded within the maternity system, and investing in better infrastructure, IT services and facilities.
Importantly, she also recommends a new statutory role of a National Maternity and Neonatal Commissioner who will be accountable to Parliament and will be involved in driving improvement and having oversight of the improvements.
Ultimately, the findings echo the concerns that have been present for some time – that the system requires significant national reform in order to prevent future harm.
How we can help
At Enable Law, we have extensive experience supporting families affected by failures in maternity care. We understand the lasting impact these experiences can have and are committed to helping families secure answers, accountability and, where appropriate, compensation. Just as importantly, we aim to support improvements in care by ensuring that lessons are learned.
If you have concerns about the care you or your family received, our specialist team is here to help. We offer clear, sensitive advice tailored to your circumstances, and can guide you through your options in a supportive and straightforward way. To talk to one of our experts, call us on 0800 044 8488 or fill in our contact form so we can call you back at a time convenient to you.
