England’s NHS maternity services are under the microscope once again, as the interim findings of the National Maternity and Neonatal Investigation (NMNI) paint a distressing picture of care that has left families reeling. The probe, led by Baroness Valerie Amos, has revealed that, despite years of warnings and hundreds of recommendations, many women and babies continue to experience unsafe, inadequate, and sometimes shocking conditions in hospitals across the country. The scale and persistence of these issues have left victims and campaigners frustrated, while officials promise that this time, real change is on the horizon.
The NMNI, launched in June 2025 and due to deliver its final report in spring 2026, is examining maternity and neonatal care at 12 NHS trusts, including the renowned Oxford University Hospitals (OUH) and the John Radcliffe Hospital. Baroness Amos, a former UN diplomat, has spent the last three months visiting seven trusts and speaking with more than 170 families, as well as NHS staff. Her initial reflections, released on December 9, 2025, have shocked even seasoned observers.
“Nothing prepared me for the scale of unacceptable care that women and families have received, and continue to receive, the tragic consequences for their babies, and the impact on their mental, physical and emotional wellbeing,” Baroness Amos wrote in her interim report, according to NationalWorld. She added that, while she expected to hear about failings, the reality was “much worse” than anticipated, as reported by BBC News.
The findings are grim. Women have described being left hungry, bleeding out in bathrooms, or forced to lie in their own blood. “There wasn’t any kindness there. I was left in my own blood,” said Rebecca Matthews, a campaigner for families failed by OUH, in an interview with Sky News. Matthews, who participated in evidence-gathering sessions, was left disappointed by the interim report. “It was a bullet point list of failings that actually we’ve seen time and time again in independent reviews. The reflections don’t mention accountability at all.”
Baroness Amos’s investigation has uncovered common themes: women not being listened to, being disregarded when raising concerns, and not being given enough information to make informed choices about their care. Discrimination is a major issue, particularly against women of color, working-class mothers, and younger parents. “There is clearly discrimination,” Baroness Amos told Sky News, noting that women sometimes make choices they know may be detrimental, simply because of previous racist experiences in healthcare settings. “Inequalities is a key strand of the work that we’re doing.”
The report also highlights shocking conditions in some hospitals. According to BBC News, mothers have been left without meals, in dirty wards, and sometimes denied help to use the bathroom or have catheters emptied. Some women who lost babies were placed on wards with newborns, compounding their trauma. There were stories of a lack of empathy from clinical teams, with women feeling blamed or guilty when things went wrong. Matthews called her care “callous,” echoing a sentiment heard from many families.
Perhaps most frustrating for campaigners is the sense of déjà vu. Over the past decade, 748 recommendations have been made to improve NHS maternity services, stemming from previous high-profile inquiries into failings at Morecambe Bay, Shrewsbury & Telford, and East Kent, among others. Yet, as Baroness Amos put it, “I do not understand why change has been so slow.” She asked, “Why are we in England still struggling to provide safe, reliable maternity and neonatal care everywhere in the country?” The latest Care Quality Commission findings show that almost two-thirds of acute hospital maternity services are either inadequate or require improvement for safety, according to Sky News.
The frustration is palpable among those who have suffered. “We need some mechanisms that are going to hold people and systems to account,” Matthews told Sky News. Emily Barley of the Maternity Safety Alliance, which is pushing for a statutory public inquiry, criticized the current review process for prioritizing staff feelings over the “avoidable harm taking place in NHS maternity services every day,” as reported by BBC News. “This is entirely the wrong process to fix the deep-seated and long-standing failings in maternity care and we do not understand why [Wes Streeting] is allowing this farce to continue.”
Baroness Amos acknowledges the skepticism and criticism from families and campaigners. “Time and time again, families feel that the system has failed them. I am very keen that that does not happen this time,” she told BBC Radio 4’s Today programme. Despite lacking the powers of a statutory public inquiry, she expressed confidence that her review would lead to “systemic changes” that improve care nationwide.
Health Secretary Wes Streeting, who ordered the investigation, has been vocal about the need for action. “The systemic failures causing preventable tragedies cannot be ignored,” Streeting said, as quoted by NationalWorld. He praised the courage of bereaved and harmed families for sharing their experiences, calling their stories “deeply distressing.” While acknowledging that “the vast majority of births are safe,” Streeting emphasized that “every single preventable tragedy is one too many.”
Streeting also announced the creation of a new National Maternity and Neonatal Taskforce, which he will chair starting in January 2026. The taskforce will be responsible for implementing the recommendations of the Amos review. “Harmed and bereaved families will remain at the heart of both the investigation and the response, to ensure no one has to suffer like this again,” he pledged, according to NationalWorld.
The review has also shed light on the difficult environment faced by NHS staff. Some have reported receiving death threats, having rotten fruit thrown at them, or being attacked on social media following negative publicity, as BBC News reported. While adverse media attention can make it harder to deliver high-quality care, staff acknowledged that it has sometimes acted as a catalyst for improvements.
Not all feedback about NHS maternity services is negative, however. OUH chief nurse Yvonne Christley noted that “feedback received from patients using our maternity service over the last year is positive overall.” Still, she admitted, “we know we have more to do to improve our maternity services. Our present focus is on listening to the experiences of women and families, which is helping us to identify opportunities for improvement,” as quoted by Sky News.
Some experts and campaigners see the current review and taskforce as a genuine opportunity. James Titcombe, a long-standing maternity safety campaigner whose son Joshua died due to hospital errors, told the Press Association, “The issues highlighted today are not new – they reflect long-standing problems we’ve known about for years, yet sadly previous efforts to deliver lasting change have fallen short. This review, and crucially the taskforce being established to turn its recommendations into action, represents the best opportunity in a generation to finally put maternity services on a safer path.”
The investigation is ongoing, with the final report expected in spring 2026. Meanwhile, the largest maternity inquiry in NHS history—examining around 2,500 cases in Nottingham—is due to report in June 2026. As the country awaits these findings, the question remains: will this be the moment when promises are finally turned into meaningful, lasting improvements for mothers and babies across England?
