An independent investigation into maternity and neonatal services in England, led by Baroness Amos, found "overall system failure" within the NHS, impacting women, babies, and staff. The inquiry, which interviewed over 400 family members and received input from more than 8,000 people, highlighted that the current system is not delivering the safe care expected and deserved, often with devastating consequences. Health Secretary Wes Streeting has acknowledged the inquiry's findings and committed to addressing its final recommendations.
The interim report, published on February 26, 2026, identified six critical factors contributing to the systemic issues: workforce shortages, capacity pressures, problematic culture and leadership, racism and discrimination, a lack of accountability for mistakes, and inadequate hospital facilities. Specific examples included community midwives being redeployed to delivery units without proper training, and instances of "cover-ups" and reluctance from trusts to admit errors or provide full explanations to bereaved families.
The inquiry also exposed distressing conditions within NHS hospitals, such as mothers giving birth in open delivery rooms, inadequate bereavement spaces, and facilities with leaking roofs. A particularly concerning finding was the practice of recording baby deaths as stillbirths to avoid coronial investigations, leaving families without answers. Families consistently reported feeling disregarded and unheard, with many experiencing a lack of kindness and compassion from staff. The report stresses that this cycle of repeated failures, despite numerous previous reviews and recommendations, must stop, emphasizing the need for systemic change rather than episodic care.
