The UK government has launched a rapid review into the maternity and neonatal services of 14 NHS Trusts following long-standing concerns over safety and care standards.
Sparked by reports of preventable baby deaths and systemic failures, the investigation aims to uncover why improvements recommended in previous inquiries have not been consistently implemented.
Led by Baroness Amos, the review will assess the experiences of patients and staff, with a particular focus on addressing racial disparities and restoring public confidence in maternity care.
What Prompted the Investigation Into the 14 NHS Trusts?
The investigation into the 14 NHS Trusts stems from years of persistent concerns about failures in maternity and neonatal care services across England.
Over the past decade and a half, numerous families have come forward to report traumatic and often tragic experiences, citing poor care, neglect, and systemic failings. These individual cases began to form a disturbing pattern across multiple NHS Trusts.
Health Secretary Wes Streeting acknowledged the courage of bereaved families who spoke up, prompting the government to initiate a rapid review of maternity services.
This review was not launched as a national inquiry, despite calls from families and advocacy groups. Instead, it focuses on selected trusts believed to represent a cross-section of issues within the system.
Previous high-profile investigations, including the Ockenden Review into Shrewsbury and Telford, and the Kirkup Report on East Kent Hospitals, revealed deep-rooted problems.
Many of those problems, such as failures in leadership, communication breakdowns, and an inability to act on previous warnings, are now being examined once more in this review.
Which NHS Trusts Are Being Reviewed and Why?
The 14 NHS Trusts were selected through a combination of data analysis, geographical representation, and feedback from families who experienced poor care.
The review committee sought to represent a diverse picture of maternity services across the country, both in terms of location and demographics.
The following table outlines each trust and the core reason it has come under review:
| NHS Trust Name | Region | Primary Concerns |
| Blackpool Teaching Hospitals | North West | Delays in maternity response times |
| Bradford Teaching Hospitals | Yorkshire | Cultural safety concerns |
| University Hospitals of Leicester | East Midlands | Oversight of high-risk pregnancies |
| Leeds Teaching Hospitals | Yorkshire | Clinical negligence complaints |
| Sandwell and West Birmingham | West Midlands | Previous safety alerts |
| Gloucestershire Hospitals | South West | Nine preventable baby deaths (2020–23) |
| Yeovil District Hospital | South West | Staff shortages in maternity wards |
| Oxford University Hospitals | South East | Communication failures |
| University Hospitals Sussex | South East | Lack of consistent care practices |
| Barking, Havering and Redbridge University Hospitals | London | History of missed incidents |
| Queen Elizabeth Hospital, King’s Lynn | East England | Low morale and clinical risks |
| University Hospitals of Morecambe Bay | North West | Already investigated (2015) |
| East Kent Hospitals | South East | Found to have poor leadership (2022) |
| Shrewsbury and Telford Hospital | West Midlands | Subject of Ockenden Review |
Each of these trusts either has an established history of care-related failings or has emerged in recent data as having high-risk indicators, particularly in birth outcomes and maternal morbidity.
Who Is Leading the Review and What Is Its Scope?
Appointment of Baroness Valerie Amos
Baroness Valerie Amos was appointed to chair the independent review into maternity and neonatal services at the 14 NHS Trusts. A crossbench peer in the House of Lords, Baroness Amos has a long-standing background in public service, human rights, and international diplomacy.
She has held positions such as UN Under-Secretary-General for Humanitarian Affairs and was the first Black woman to serve in the British Cabinet.
Her leadership in this review brings both political independence and experience in handling complex, high-impact investigations.
Objectives of the Review
The primary goal of the review is to assess why prior recommendations across multiple investigations have failed to result in long-term, measurable improvements.
This includes understanding how systemic barriers, leadership breakdowns, and operational inefficiencies continue to impact maternity safety across NHS Trusts.
Key objectives include:
- Gathering direct testimony from affected families and healthcare staff
- Evaluating whether past recommendations have been properly implemented
- Identifying common failures in clinical governance and leadership
- Understanding regional, demographic, and structural disparities in outcomes
Timeline and Deliverables
Initially scheduled to conclude in December 2025, the review has now been extended to report fully by Spring 2026. This extension was made to ensure comprehensive evidence gathering and allow for thorough engagement with families and NHS staff.
A set of interim findings is expected around Christmas 2025, which will include early recommendations that could be actioned prior to the final report.
Scope of Inclusion and Exclusion
Although the review is wide in scope, it has faced criticism for excluding direct examination of national regulatory bodies like the Care Quality Commission (CQC) and NHS Resolution.
Baroness Amos has clarified that while these organisations are not the central focus, their role will not be entirely ignored. The review will consider systemic influences but cannot conduct statutory investigations due to legal limitations.
What Are the Key Issues in NHS Maternity and Neonatal Services?
Clinical Failures in Care
Many of the trusts under investigation have demonstrated repeated clinical failures in managing pregnancy, labour, and postnatal care. These failures include delayed diagnosis, inadequate response to emergencies, and mismanagement of high-risk pregnancies.
Key patterns in clinical care concerns:
- Failure to act on foetal distress or maternal complications
- Missed diagnoses of gestational diabetes, pre-eclampsia, or infection
- Incomplete monitoring of babies during labour
- Inadequate documentation of care plans
These errors often lead to birth trauma, neonatal injury, and in the most severe cases, preventable deaths of babies or mothers.
Communication and Patient Engagement
Across numerous reports, communication breakdowns have been consistently cited. Families have spoken of not being listened to during labour, having their concerns dismissed, or receiving insufficient explanations about what went wrong.
Common complaints include:
- Failure to obtain informed consent
- Poor coordination between midwives, doctors, and anaesthetists
- Dismissive attitudes towards women in labour
- Families being excluded from decision-making processes
This lack of patient-centred care creates distrust and increases the emotional trauma families experience after an adverse event.
Leadership and Governance Gaps
Several trusts have suffered from weak leadership structures, where senior staff failed to escalate concerns or act on early warnings. In some instances, leadership teams have been accused of creating a culture of fear, where staff were reluctant to raise issues.
Typical governance failures include:
- Inconsistent safety protocols across maternity units
- Lack of incident reporting or delayed responses to serious incidents
- Poor handover processes between departments
- Minimal learning from adverse outcomes
This lack of accountability contributes to a repeating cycle of preventable errors and institutional denial.
Cultural and Workforce Pressures
A significant underlying issue is the staffing crisis within maternity services. High vacancy rates, poor staff retention, and burnout are placing immense pressure on existing teams.
The Royal College of Obstetricians and Gynaecologists has reported that many maternity professionals are leaving the workforce due to stress and fear of litigation.
Current challenges faced by staff:
- Insufficient midwife-to-patient ratios
- Overstretched rotas and limited training time
- Low morale and a lack of emotional support
- Fear of being blamed rather than supported during investigations
This challenging environment not only affects staff well-being but directly impacts the quality of care provided to mothers and babies.
Repeated Failures to Learn from Previous Reviews
Despite extensive recommendations made in the Morecambe Bay, East Kent, and Shrewsbury and Telford inquiries, many of the same failings are now being identified again. Trusts have been criticised for failing to treat these findings as urgent or universally applicable.
The current review aims to understand:
- Why recommendations were not consistently implemented
- How oversight mechanisms failed to ensure accountability
- Whether internal audits at trust-level were effective or superficial
- How NHS England supported or monitored compliance
This raises a broader question about the NHS’s capacity for systemic learning and long-term reform.
How Have Families and Advocacy Groups Responded?
Families directly affected by maternity negligence have played a key role in bringing this review to light. Their experiences have ranged from loss and trauma to long-term health complications caused by preventable errors during childbirth.
While many families see the review as an important recognition of their suffering, others are critical of its structure. The Maternity Safety Alliance (MSA), a coalition of bereaved and affected families, has voiced strong opposition to the limitations of the review.
Key concerns raised include:
- The exclusion of NHS regulators like the Care Quality Commission and NHS Resolution
- Lack of formal investigation powers, which a statutory public inquiry would have
- A perceived bias in placing blame solely on clinicians and local trusts, rather than examining national systems
Several families have stated they feel “used” by the process and are frustrated that real accountability may once again be sidestepped. There is also concern that rapid timelines may compromise the quality of the evidence gathered and the support available for those giving testimonies.
Some, including the families of Kate Stanton-Davies and Pippa Griffiths, acknowledge the review as an important step but urge that it be conducted slowly and with a strong mental health support framework in place for contributors.
What Role Do NHS Regulators and Oversight Bodies Play?
The omission of formal scrutiny into NHS regulators has emerged as a key source of controversy. Critics argue that a meaningful investigation cannot be complete without examining the role of oversight bodies like:
- The Care Quality Commission (CQC)
- NHS Resolution (handling legal claims)
- Local Integrated Care Boards
These bodies have been responsible for evaluating and addressing risks in hospitals, yet their interventions have sometimes failed to prevent ongoing harm. In several cases, trusts were rated “good” even as reports of serious incidents increased.
Baroness Amos has acknowledged the importance of including regulatory oversight in the review’s context, but also clarified that the type of in-depth inquiry families are demanding exceeds the scope and timeline of the current review.
The MSA has responded by calling the review “not fit for purpose” and continues to demand a statutory public inquiry that would legally compel regulators and senior officials to provide evidence.
Why Are Black and Asian Families at Higher Risk?
One of the most distressing aspects of the maternity crisis in England is the racial disparity in outcomes. Black and Asian families are statistically more likely to experience adverse maternity events, including maternal and neonatal mortality.
A 2023 report from MBRRACE-UK highlighted that:
- Black women are nearly four times more likely to die in pregnancy or childbirth than white women
- Asian women are twice as likely to experience serious complications
- These disparities persist regardless of income or education levels
Baroness Amos has committed to placing specific focus on these disparities in her review. She stressed the importance of investigating how institutional racism, communication barriers, and assumptions about pain thresholds contribute to differential outcomes.
By integrating an equity lens into the findings, the review aims to ensure that recommendations will address not only safety and quality, but also fairness and inclusion.
The following table outlines known disparities based on ethnicity:
| Ethnic Group | Relative Risk of Maternal Mortality | Common Contributing Factors |
| Black British | 3.7x higher than white women | Implicit bias, poor follow-up care |
| Asian British | 2x higher than white women | Language barriers, delayed diagnosis |
| White British | Baseline | Lower rate of adverse outcomes |
Addressing these disparities will require targeted reforms, including better cultural competency training, inclusive clinical guidelines, and improved data transparency.
Conclusion
The inclusion of 14 NHS Trusts in this nationwide review signifies a pivotal moment for the future of maternity and neonatal care in the UK. While the intentions of the review are clear, its success will depend heavily on transparency, accountability, and the system’s willingness to act on its findings.
Whether this process will deliver the justice families have long sought remains to be seen, but for many, it represents a necessary, if overdue, step toward systemic change.
FAQs
What is the aim of the current NHS maternity care review?
The review aims to investigate failings in maternity and neonatal services across 14 NHS Trusts and identify why past improvements have not been implemented effectively.
Why were only 14 NHS Trusts selected?
The trusts were chosen based on patient data, family testimonies, and to ensure a mix of geographic and demographic representation.
Who is Baroness Amos and what is her role?
Baroness Amos is the appointed chair of the review, responsible for overseeing the inquiry, compiling findings, and producing recommendations for reform.
How do previous maternity scandals relate to the current review?
The current review builds on lessons from previous investigations, focusing on recurring issues like unsafe care, poor leadership, and failure to act on recommendations.
What are the concerns about NHS regulators?
Many families believe regulators such as the CQC and NHS Resolution have not done enough to prevent recurring failures, leading to calls for a statutory inquiry.
How is the government addressing racial disparities in maternity outcomes?
The review will specifically investigate the disproportionately poor outcomes for Black and Asian families and propose targeted improvements.
When will the final report be released?
The review is expected to release interim findings by Christmas 2025 and a full report by Spring 2026.
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