Women left bleeding in bathrooms, babies dying needlessly, and families enduring unimaginable trauma—these are just some of the harrowing realities exposed by the latest interim findings of the National Maternity and Neonatal Investigation (NMNI) into NHS maternity care in England. Led by Baroness Valerie Amos, the probe has shone a stark light on systemic failures and a culture that, despite years of warnings and hundreds of recommendations, has not delivered the safe, compassionate care mothers and infants deserve.
Baroness Amos, a seasoned public servant, admitted to Sky News and BBC Radio 4 that even she was unprepared for what she found. “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,” she stated in her December 9, 2025, report. Her investigation, which is scrutinizing 12 NHS trusts, has already led to a “staggering” 748 recommendations about maternity and neonatal services in recent years.
But why, after so many warnings, is England still struggling to provide safe and reliable maternity care everywhere? The interim report paints a picture of a system in crisis. According to The New Statesman, the Care Quality Commission found in 2024 that nearly two-thirds (65%) of England’s maternity units required improvement or were outright inadequate. These issues are not simply the result of staff shortages, low morale, or funding gaps. As commentator Hannah Barnes observed, “This is a problem of culture.”
Baroness Amos’s findings echo this sentiment. She consistently heard from women who felt “blamed and guilty” for their baby’s death, who experienced “a lack of empathy, care or apology” when things went wrong. Women reported being disregarded when raising concerns, not being given the information needed to make informed choices, and facing discrimination—particularly women of colour, working-class women, younger parents, and those with mental health challenges. “Women are bleeding out in bathrooms… the poor basic care they receive, the lack of attention,” Amos told the BBC. Some women were left for hours without care, while others went hungry due to missed meals. Wards were often unclean, and, heartbreakingly, women who lost babies were sometimes placed on wards with newborns.
The investigation also revealed that hospital staff have suffered as well, with some facing harassment and threats following negative publicity about their units. Despite this, Amos thanked families for their “constructive and honest feedback” and NHS staff for their dedication, acknowledging the courage required to share such painful experiences.
One particularly tragic story is that of Robert Miller, whose daughter Abigail died aged two days at the Royal Sussex County Hospital in 2022 following an emergency Caesarean. An inquest found Abigail’s life could have been prolonged if her mother had been admitted sooner. Miller told the BBC, “It’s not shocking to us, we’ve been there, we’ve seen it, we’ve lived it. I think it’s important that she sees the depth and trauma that families have suffered, so I’m pleased that she’s acknowledged that.” Still, Miller and other bereaved families have expressed disappointment at the slow pace of the investigation, calling for it to “progress a bit further, a bit quicker.”
University Hospitals Sussex NHS Foundation Trust, which runs the hospital where Abigail died, is among the trusts being investigated. Although it has offered “condolences and sincere apologies” to Abigail’s family and claims “key maternity safety measures have improved significantly” since, it will not be visited or asked for documents until 2026. Miller looks forward to meeting Baroness Amos when she visits Sussex, determined to ensure the failings that led to his daughter’s death are heard.
Other families have echoed these frustrations. Emily Barley, whose daughter Beatrice died at Barnsley Hospital in 2022, told the BBC that her healthy baby “died because of really basic failings in care and also cruelty by staff.” She described staff shrugging off her concerns and even laughing as her baby died. Barley called the new review “superficial” and lacking in depth, a sentiment shared by many campaigners who fear that recommendations will once again lack the teeth needed for real change.
The roots of these systemic problems are complex. The Sunday Times highlighted how some hospitals, such as Leeds Teaching Hospitals Trust, pursued a “normal birth” ideology for over a decade, actively promoting vaginal births with minimal medical intervention. While this led to the lowest caesarean section rates nationwide, it also coincided with soaring rates of stillbirths and newborn deaths. Although the Royal College of Midwives abandoned its “normal birth” campaign in 2017, nearly two-thirds of universities still promote this ideology in midwifery courses, according to a 2025 investigation.
Public inquiries have repeatedly exposed issues such as poor communication, a reluctance to learn from mistakes, and a defensive culture. The Ockenden review noted that midwives and obstetricians often work in silos, and families’ concerns are routinely downplayed or dismissed. Former health secretary Jeremy Hunt, writing in The Guardian, identified “a blame culture that stopped people being open about mistakes” as the biggest barrier to safer care. More than a third of NHS staff say they “don’t feel comfortable speaking up about safety concerns,” which prevents learning from tragedies and perpetuates the cycle of failure.
Health secretary Wes Streeting, who ordered the NMNI probe in June, acknowledged the distressing nature of the findings and praised the courage of bereaved families. “I know that NHS staff are dedicated professionals who want the best for mothers and babies, and that the vast majority of births are safe, but the systemic failures causing preventable tragedies cannot be ignored.” Streeting is establishing a National Maternity and Neonatal Taskforce in the new year to drive improvements, a move welcomed by campaigners and medical professionals alike.
Yet, the central question remains: why has change been so slow? As Angela McConville, chief executive of the National Childbirth Trust, put it, “While some women do have safe, positive and supported experiences, the inconsistency of care is unacceptable. None of this is new. As the report highlights, almost 750 recommendations have already been made to improve maternity and neonatal care. The question the investigation and the maternity taskforce must now answer is simple: why has change not happened?”
Baroness Amos’s full report is expected in spring 2026, with site visits and evidence collection ongoing. For families like the Millers and the countless others who have endured loss and trauma, the hope is that this time, the recommendations will lead to real, lasting change—before more lives are needlessly lost.
