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17 October 2025

Calls For Reform Intensify After Maternity Tragedies

Bereaved families and campaigners push for urgent improvements in England’s maternity care after a series of preventable deaths and high-profile investigations.

Across England, a growing chorus of families and campaigners is demanding urgent improvements in maternity care after a series of tragedies and a national review that has cast a spotlight on persistent failings in the system. Recent cases from Gloucestershire, Birmingham, and London have underscored the pain and frustration experienced by bereaved families, and prompted pledges of reform from NHS trusts and advocacy groups alike.

In Gloucestershire, a report presented to the county council's health overview and scrutiny committee on October 14, 2025, revealed that between 2020 and 2023, 44 neonatal deaths occurred at local hospitals, alongside seven maternal deaths since 2017. The findings, reported by BBC Gloucestershire, have triggered both public outcry and institutional soul-searching. Councillor Rebecca Trimnell did not mince words as she addressed the committee: "I had my daughter 20 years ago and if I was a pregnant mother now going to give birth I would be absolutely petrified." She questioned the safety of reopening the Aveta unit, stating, "Is it because it would be unsafe to open it and therefore I wouldn't want to see it open if it wasn't being staffed correctly?"

The trust’s chief executive, Kevin McNamara, acknowledged the gravity of the situation, noting, "We know that sort of fear might drive choices that may not be helpful to mums." He emphasized that the trust’s role is "not downplaying the issues" but rather explaining the steps being taken to improve, which include staff recruitment, better oversight, and fostering a "safer culture" where staff feel empowered to speak up. McNamara reassured the public, "The vast majority of women who come through the doors of our hospital have no issue." Matt Holdaway, quality and chief nurse director, added that there is evidence of improvement and reiterated the trust’s commitment to making maternity services a central focus.

Two external reviews have been commissioned to examine the deaths and identify lessons that could prevent future tragedies. The reviews found that missed opportunities may have improved the outcomes in nine of the neonatal deaths. The trust has since implemented a series of changes aimed at addressing these issues, including enhancements in staffing and organizational culture.

Elsewhere in England, similar stories of heartbreak and calls for change are emerging. In Birmingham, Hayleigh Richards endured every mother’s nightmare in July 2023 when her baby boy, Reggie, was stillborn at the former City Hospital. According to BBC News, Mrs. Richards was twice sent home from the hospital while in early labor. On her third visit, doctors could not detect Reggie’s heartbeat. The pain is still raw for the family. Her husband, Samoye Richards, reflected, "The feelings, I just can't put into words, our lives just crumbled." He added, "It's been a couple of years now but the effects from that will be with us forever, I see it every day in my wife, Hayleigh."

Reggie’s grandmother, Lisa Blackstock, spoke of her anger and the trust she had placed in medical staff: "I was really, really angry but you put your trust in the midwives, you put your trust in the hospital. It was her first baby." The family has since instructed solicitors to investigate Reggie's death, with Leanne Atkinson, a lawyer from Irwin Mitchell, stating, "Our concerns are centred around Hayleigh's attendances at the hospital. We feel that more should have been done to listen to Hayleigh."

The Sandwell and West Birmingham Hospitals NHS Trust, which managed the hospital at the time, is one of 14 trusts currently under a rapid review of maternity care in England. Chief executive Diane Wake expressed deep regret: "Our thoughts and heartfelt sympathies are with his family. This tragic incident, which occurred in 2023, was fully investigated by the independent Maternity and Newborn Safety Investigations programme. We have taken forward all recommendations from that investigation to strengthen our maternity pathways and ensure families receive safer and more compassionate care."

The trust has pledged to work openly with the national review team, which is chaired by Baroness Amos. The review aims to ensure that families affected by maternity care failures are heard and that the investigations will lead to improvements nationwide. Advocacy groups, including the community interest company Make Birth Better, have formed a working group of 99 organizations to lobby for systemic changes. Laura Rose Thorogood, the group’s chief executive, said, "It's making sure everyone is brought to the forefront, everyone is heard and we address those poor inequalities of those families and staff."

Stories like that of Sarah and Andrew Conroy from Sevenoaks, Kent, add a deeply personal dimension to the national reckoning with maternity care standards. As reported by Irwin Mitchell, the couple spent four years trying for their "miracle" baby, Kit, only to lose him at just six hours old after a three-hour delay in providing a potentially life-saving blood transfusion at London’s University Hospital Lewisham. Sarah had suffered a serious bleed during labor, known as an antepartum haemorrhage, but Kit did not receive the emergency transfusion until three hours after his birth. The hospital trust admitted to breaches of duty regarding the delay and the insufficient volume of blood administered, but denied liability for Kit’s death. An out-of-court settlement was eventually reached.

Sarah recounted the couple’s ordeal: "We’d called Kit our little miracle. I’d had surgery to remove fibroids and despite years of trying it felt like we were never going to have any joy. We were overjoyed that our dream of having a baby was coming true." The day Kit was born, she recalled, "should have been the happiest of our lives but it turned to absolute despair. I don’t think we’ll ever get over leaving hospital and not taking Kit with us to start our new lives together."

Sarah and Andrew have since become vocal campaigners for improved maternity safety, sharing their story during Baby Loss Awareness Week and urging hospital trusts to work more collaboratively with families. "There continues to be too many families affected by poor maternity care that we can’t sit by and do nothing. If by sharing our story we can help empower families to ask questions and improve care then maybe Kit’s death won’t have been totally in vain," Sarah said.

The couple’s lawyer, Elaine Farr, emphasized the broader implications: "While we’re pleased to have secured answers and a settlement, allowing Sarah to access the specialist support she requires, the impact of what happened to Kit is profound and life-altering for both Sarah and Andrew. It’s now vital that lessons are learned from the issues identified in Sarah’s case to improve maternity safety for others."

Across the country, these deeply personal stories are fueling a movement for change. Families, advocacy groups, and legal experts are insisting that lessons from past tragedies translate into concrete improvements. While NHS trusts have begun to implement reforms and external reviews are underway, the voices of those most affected remain clear: every family deserves safe, compassionate, and attentive maternity care—and their stories must be heard if real progress is to be made.