On September 15, 2025, the UK government made a striking announcement: fourteen NHS trusts across England will undergo a sweeping investigation into what Health Secretary Wes Streeting described as “systemic failures” in maternity and neonatal care. This rapid review, originally announced in June and now set to conclude in Spring 2026, marks one of the most comprehensive efforts to confront persistent problems in the country’s maternity services—a sector that, for more than 15 years, has been haunted by tragedy, scandal, and repeated calls for reform.
The fourteen trusts under scrutiny—stretching from Blackpool to East Kent—represent a cross-section of England’s geography and demographics. According to the Department of Health, their selection was based on a combination of data analysis, family testimonies, and the need for diversity in the review’s scope. Among the trusts named are Blackpool Teaching Hospitals, Bradford Teaching Hospitals, University Hospitals of Leicester, Leeds Teaching Hospitals, Sandwell and West Birmingham, Gloucestershire Hospitals, Yeovil District Hospital, Oxford University Hospital, University Hospitals Sussex, Barking, Havering and Redbridge University Hospitals, Queen Elizabeth King’s Lynn, University Hospitals of Morecambe Bay, East Kent Hospitals, and Shrewsbury and Telford Hospital.
Baroness Amos, appointed to lead the investigation, emphasized her commitment to ensuring that the voices of families affected by maternity care failures are not only heard but central to the process. In an interview with BBC Radio 4, she said, “I hope this review will help families get the justice that they want and that they deserve.” She acknowledged the “completely unacceptable” reality that, despite previous inquiries and “hundreds” of recommendations, new reviews are still needed because improvements have not stuck. “The kind of in-depth review that is being requested is not something that I am able to conduct,” she admitted, noting the time constraints but insisting regulatory bodies were “not excluded.”
Health Secretary Wes Streeting echoed these concerns, stating, “What they have experienced is devastating and their strength will help protect other families from enduring what they have been through. Every single preventable tragedy is one too many. Harmed and bereaved families will be right at the heart of this investigation to ensure no-one has to suffer like this again.” Streeting acknowledged that bereaved families had often been “gaslit” in their search for the truth, and that “too much passing the buck” had occurred between NHS trusts and regulators. He praised the extraordinary courage of families who had come forward—some with stories dating back more than 15 years.
The review is not the first attempt to address failings in maternity care. Previous high-profile inquiries—such as those at Morecambe Bay, East Kent, and Shrewsbury and Telford—have exposed issues ranging from women’s voices being ignored and safety concerns overlooked, to poor leadership and toxic workplace cultures. Yet, as Baroness Amos pointed out, the fact that families are still reporting substandard care shows how little has changed. According to research by baby loss charities Sands and Tommy’s, improved maternity care could have prevented more than 800 baby deaths in 2022-23 alone.
Despite the review’s ambition, it has faced sharp criticism from some advocacy groups and bereaved families. The Maternity Safety Alliance (MSA), representing families harmed by poor maternity care, accused Streeting of breaking promises about the investigation’s scope. They argue that the review unfairly places all responsibility on NHS trusts and clinicians, ignoring the role of regulators such as the Care Quality Commission and NHS Resolution. Tom Hender, who lost his son Aubrey in 2022, said, “That’s just not true—the whole system is in crisis and we need a whole system approach.” The MSA has labeled the investigation “not fit for purpose,” declaring, “It is clear that only a statutory public inquiry can end the crisis in maternity care.”
Others, however, see the review as a necessary step forward. The families who successfully campaigned for the Shrewsbury and Telford inquiry described the new investigation as “an important and brave first step,” though they cautioned that it would be “safer” to proceed at a slower pace and called for robust mental health support for families sharing their experiences. “It’s not enough to have a nominal support figure in the room and an email address for follow-up,” they stated, underscoring the emotional toll of reliving traumatic events.
Professional bodies have weighed in as well. The Royal College of Obstetricians and Gynaecologists warned that the review would “create real anxiety among women, families and staff” at the affected trusts, but acknowledged its potential to help rebuild a world-class maternity system. “Too many women and babies are not getting the safe, compassionate care they deserve and the maternity workforce is on its knees, with staff leaving the profession,” said the college’s president, Professor Ranee Thakar. The Royal College of Midwives (RCM) echoed the urgency, calling for support for both staff and families and highlighting that “it should not be the case that, in 21st-century Britain, black and Asian women are disproportionately more likely to die during childbirth or soon after, or that their babies are more likely to have poorer outcomes.”
Indeed, Baroness Amos has pledged “particular attention” to the persistent inequalities affecting black and Asian families, whose outcomes continue to lag behind those of their white counterparts. To address these disparities, the government is rolling out a new digital system by November 2025 to flag potential safety concerns in maternity services, alongside an anti-discrimination program targeting care inequalities for minority and deprived communities.
The challenges facing maternity services are not just about culture and leadership—they are about infrastructure, too. On September 8, 2025, a review found that nine baby deaths at Gloucestershire Hospitals NHS Trust between 2020 and 2023 could have been prevented. Days later, a report revealed that more than half of NHS trusts rated their maternity and neonatal buildings as unsatisfactory, with 7% warning of a serious risk of imminent breakdown. These findings paint a picture of a system under immense strain, with both physical and human resources stretched to the limit.
Rory Deighton, director of the acute network at the NHS Confederation, acknowledged the gravity of the situation: “NHS leaders and their teams work very hard to keep mothers and their babies safe but accept that there needs to be improvements in maternity services. There are ongoing challenges around safety, equity and staffing shortages and this inquiry presents an important opportunity to support front-line maternity services to improve where needed.” He added, “It’s vital that we learn from failings in maternity services so that care can be made safer for all women and babies.”
Meanwhile, the chief executive of the General Medical Council, Charles Massey, is expected to address a conference in Manchester about what he calls a “toxic” culture of cover-up in the NHS—one that he says is leading to poor maternity outcomes and the normalization of harm to mothers and babies. “Patient safety is falling victim to unhealthy culture,” Massey will say, according to advance remarks shared by the GMC.
As the investigation gets underway, Baroness Amos aims to deliver interim findings around Christmas 2025, with the final report due in Spring 2026. Whether the review will finally deliver lasting change remains to be seen. But for the families at the heart of this story, the hope is that their courage and persistence will help ensure no one else endures the pain they have suffered—and that the NHS can once again become a place where every mother and baby receives the care they truly deserve.
