Lauren Caulfield never imagined that the birth of her daughter, Grace, would end in heartbreak. In 2022, after months under the care of Leeds Teaching Hospitals Trust and Bradford Teaching Hospitals Trust, Lauren’s world was shattered when Grace was stillborn. The tragedy was not a freak occurrence but, as later revealed, the result of failings in her care—failings that have come to represent a deeper malaise within England’s maternity services.
This week, the UK government thrust the issue of maternity care back into the national spotlight. On Monday, September 15, 2025, officials announced a rapid review of maternity and neonatal services at 14 NHS trusts across England, including the Leeds and Bradford trusts that cared for Lauren Caulfield. The review, first announced in June, is set to report preliminary findings by December 2025 and aims to address what Health Secretary Wes Streeting called “failures in the system.”
But for Lauren and many others, the government’s response falls short. “All we have had is briefing sessions and being told what they are going to do, rather than being part of this process,” Lauren told BBC. She’s a member of the Maternity Safety Alliance, a group of families harmed by poor maternity care across England, and she’s not alone in her skepticism. “The timescale given for the review, which is due to report back by December, would make its findings shallow and surface-level,” she said. “[It] isn’t going to look at the deep-rooted issues in maternity services.”
These concerns are not just about one family’s tragedy. An independent investigation by the Healthcare Safety Investigation Branch found numerous failings in Lauren’s care at both Leeds and Bradford teaching hospitals. The Maternity Safety Alliance, which has participated in meetings with the Department of Health, accuses the government of breaking promises about the scope and inclusivity of the investigation. In their view, families have been left feeling “used.”
The government’s rapid review will focus on 14 NHS trusts, a list that reads like a roll call of institutions at the center of recent scandals. Alongside Leeds and Bradford, the other trusts include Barking, Havering and Redbridge University Hospitals; Blackpool Teaching Hospitals; East Kent Hospitals; Gloucestershire Hospitals; Oxford University Hospitals; Sandwell and West Birmingham Hospitals; Shrewsbury and Telford Hospital; The Queen Elizabeth Hospital, King’s Lynn; University Hospitals of Leicester; University Hospitals of Morecambe Bay; University Hospitals Sussex; and Yeovil District Hospital/Somerset NHS Foundation Trust.
According to The Guardian, the investigation is being led by Valerie Amos and will draw on lessons from previous inquiries to create one “clear set of actions” aimed at improving NHS care. A maternity and neonatal taskforce, chaired by Health Secretary Wes Streeting and made up of experts and bereaved families, will inform the process.
Streeting acknowledged the pain and courage of those who have come forward: “Bereaved families have shown extraordinary courage in coming forward to help inform this rapid national investigation alongside Baroness Amos. What they have experienced is devastating, and their strength will help protect other families from enduring what they have been through.” He added, “I know that NHS maternity and neonatal workers want the best for these mothers and babies, and that the vast majority of births are safe and without incident, but I cannot turn a blind eye to failures in the system. 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.”
But the problems run deeper than individual mistakes or isolated incidents. Charles Massey, chief executive of the General Medical Council (GMC), delivered a sobering warning at a conference in Manchester on Monday. He said a “toxic cover-up culture” in the NHS risks normalizing harm to mothers and babies, especially when trainee doctors feel too fearful to speak up about mistakes or concerns. “Something must have gone badly wrong when trainee obstetrics and gynaecology doctors are fearful of speaking up,” Massey stated, as reported by The Guardian. He described the “tribal” nature of medicine, where staff are pitted against each other, potentially preventing candor and honesty when things go wrong.
GMC data paints a worrying picture. More than one in four (27%) obstetrics and gynaecology trainees admit they have felt hesitant about escalating a patient issue to a more senior medic—a higher proportion than in other specialties. The field also reports above-average rates of workload stress, bullying, and doctors who feel unsupported by colleagues. Massey warned, “Those are the very factors that lead to cover-up over candour and obfuscation over honesty. And it is in those cultures that the greatest patient harm occurs.”
He continued, “Everyone in this room will be aware of the scandals of recent years concerning maternity care. This is one of the most high-risk and high-pressure areas of medicine. One where the consequences of things going wrong can be especially tragic and far-reaching, affecting both a mother and her baby, not to mention their wider family.” Massey cautioned that “the unthinkable—harm to mothers and their babies—is at risk of being normalised. And toxic culture is in no small part to blame.”
The trusts under review have responded by expressing support for the investigation and regret for past failings. Professor Mel Pickup, chief executive for Bradford Teaching Hospitals NHS Foundation Trust, told BBC, “We fully support the aim of the investigation, that will have families at its heart, to develop one set of national recommendations to drive improvements in maternity and neonatal services across England. Every year, thousands of women give birth in our hospitals and community, and we want each and every one of those women to receive excellent care and have a positive experience with us. In the majority of cases this is happening, but not always, and we know that isn’t good enough.”
Dr Magnus Harrison, chief medical officer at Leeds Teaching Hospitals NHS Trust, echoed those sentiments: “We welcome the inclusion of Leeds in the national maternity and neonatal investigation and fully support its focus on improving maternity and neonatal safety across the country. We recognise we have not always delivered the highest quality of care to every family, and we are extremely sorry to the families who have lost their babies or had poor experiences when receiving care in our hospitals. Families will be at the heart of this national investigation, and we are fully supportive of this.”
For families like Lauren Caulfield’s, apologies and promises of change are only the beginning. “If I don’t push for improvements, no one will ever do anything about it,” Lauren said. The hope is that this time, the system will listen—and act—before another tragedy repeats itself.
