Fourteen NHS hospital trusts in England are set to undergo a sweeping national investigation into failures in maternity and neonatal services, following years of mounting concerns, tragic outcomes, and persistent calls for reform. This latest probe, announced on September 15, 2025, marks an expansion of the government’s previously promised review, with the goal of placing bereaved families at the heart of the process and driving long-overdue improvements across the system.
Baroness Valerie Amos, a respected crossbench peer, has been appointed to lead the investigation. She faces a formidable challenge: addressing systemic problems in NHS maternity care that have persisted for more than 15 years. According to the BBC, the investigation was prompted in part by independent reviews at multiple trusts that uncovered a litany of failings, including women’s voices being ignored, safety concerns overlooked, and poor leadership fostering toxic workplace cultures. The review will now scrutinize the following 14 NHS trusts: Barking, Havering and Redbridge University Hospitals; Blackpool Teaching Hospitals; Bradford Teaching Hospitals; East Kent Hospitals; Gloucestershire Hospitals; Leeds Teaching Hospitals; Oxford University Hospital; 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.
Health Secretary Wes Streeting, in announcing the expanded review, praised the “extraordinary courage” of bereaved families who have come forward to share their experiences. “What they have experienced is devastating and their strength will help protect other families from enduring what they have been through,” he said. “Every single preventable tragedy is one too many.” Streeting emphasized that while the majority of births are safe, the government cannot turn a blind eye to failures in the system. He also acknowledged that harmed and bereaved families would be central to the investigation’s work, ensuring that “no-one has to suffer like this again.”
Baroness Amos echoed these sentiments, telling BBC Radio 4’s Today programme, “I want to make sure that the systems and processes are in place that enable the families to get the justice that they want and that they deserve. What we have now is completely unacceptable—how we have got to a situation where so many trusts have been investigated; where we have hundreds of recommendations, and yet still, the Secretary of State has had to ask me to look again so that we pull together a set of national recommendations.” She committed to ensuring that the experiences of mothers, fathers, and non-birthing partners—especially those from black, Asian, and marginalized communities—would “guide our work and shape the national recommendations we will publish.”
The investigation is being launched against a backdrop of ongoing distress and frustration among families and campaigners. Some, like bereaved mother Emily Barley, whose daughter Beatrice died in 2022, have called for a statutory public inquiry instead of the current format. “We feel really, really let down,” Barley told BBC Radio 4. “What we’re asking for is for the investigation in this format to be scrapped and for us to have a statutory public inquiry, which is the only way for us to get into all the issues in all their detail and complexity.”
Criticism has also come from campaign groups representing families harmed by poor maternity care. The Maternity Safety Alliance (MSA), which includes families affected by failures at several of the named trusts, accused Health Secretary Streeting of “broken promises” regarding the scope of the investigation. The MSA is especially critical of the decision not to examine the role of NHS regulators, such as the Care Quality Commission and NHS Resolution. “The review seems to have already decided that all the responsibility for these 800 deaths a year lies squarely with NHS trusts and the clinicians who work in them,” said Tom Hender, who lost his son Aubrey in 2022. “That’s just not true—the whole system is in crisis and we need a whole system approach.” The group maintains that only a statutory public inquiry can end the crisis in maternity care.
Other families and campaigners have voiced a mix of relief and skepticism. For example, Rebecca Matthews, co-founder of Families Failed by OUH Maternity Services, said her group was “pleased and relieved” that Oxford University Hospitals Trust was included in the investigation after “15 months of accounts of shockingly poor and negligent care.” Yet the Bereaved and Harmed Families in Leeds expressed doubt that the review would “scratch the surface of the frontline care failings at Leeds maternity, let alone get anywhere near a culture that incubates these practices, or the leadership and people that allow these terrible cultures to perpetuate.”
The Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG) have both called for urgency, transparency, and support for staff and families. RCM chief executive Gill Walton stressed the need for the investigation to get underway swiftly: “It is vital this work gets under way quickly so that the families who have suffered unimaginable harm get the answers they need and hard-pressed maternity staff get the support and investment they’ve been calling for.” Walton also highlighted the troubling reality 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.”
Professor Ranee Thakar, president of the RCOG, warned that the review would “create real anxiety among women, families and staff” at the affected trusts. She said, “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.” Rory Deighton, director of the acute network at the NHS Confederation, added, “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.”
Recent events have underscored the urgency of the review. Last week, a review at Gloucestershire Hospitals NHS Trust found that nine baby deaths between 2020 and 2023 could have been prevented. Additionally, a separate report revealed that over half of NHS trusts rated their maternity and neonatal buildings as unsatisfactory, with 7% warning of a serious risk of imminent breakdown. The General Medical Council’s chief executive, Charles Massey, is expected to highlight how a “toxic” culture of cover-up in the NHS is leading to poor maternity outcomes and that “the unthinkable—harm to mothers and their babies—is at risk of being normalised.”
The Department of Health has said that the 14 trusts were selected based on data analysis, input from families, and to ensure a mix of geographic and demographic factors. The review, originally intended to report by December 2025, has now been extended, with Baroness Amos aiming to produce interim findings around Christmas and a final report by Spring 2026. She has insisted that, while regulatory bodies are not excluded, the kind of in-depth inquiry some families are demanding is beyond the scope of this investigation.
As the review gets underway, the hopes and anxieties of families, campaigners, and NHS staff are running high. Whether this investigation can deliver the justice, transparency, and systemic change that so many have sought for so long remains to be seen—but for now, it marks a critical moment in the ongoing struggle to make maternity care in England safer and more equitable for all.
