More than 8,000 families have contributed evidence to a major national inquiry into maternity services in England. Their experiences reveal a deeply concerning picture: while some families receive excellent care, others are exposed to serious and avoidable risks.
The interim findings from the independent investigation led by Baroness Valerie Amos identify widespread systemic failings across 14 NHS trusts. These failures have placed patient safety at risk, disproportionately affected women from ethnic minority backgrounds, and undermined confidence in maternity services.
The inquiry highlights an urgent need for cultural and structural reform across the NHS.
Six systemic failures were identified
The investigation examined 14 NHS trusts selected based on perinatal mortality rates, patient survey data and geographic spread. Evidence from hundreds of detailed family accounts points to six recurring areas of concern:
- Chronic staffing shortages
- Capacity pressures across services
- Poor leadership and workplace culture
- Racism and discrimination
- Lack of transparency and accountability
- Deteriorating hospital infrastructure
Capacity pressures affecting patient care
Women reported insufficient time during antenatal appointments, particularly those with complex medical needs. Long waits in triage and assessment units were described as routine. Planned inductions and caesarean sections were frequently delayed.
Such pressures create avoidable stress during what should be a carefully supported and monitored period.
Staffing shortages and continuity of care
The inquiry found that community midwives are regularly redeployed into hospital units to fill staffing gaps. This disrupts continuity of care and weakens both community and hospital services.
Staff required to work in unfamiliar departments reported reduced confidence and increased reliance on colleagues. This constant reshuffling risks diminishing the quality and safety of care.
Leadership and workplace culture concerns
Evidence also pointed to troubling workplace dynamics. Reports included:
- Verbal aggression by senior clinicians
- Avoidance of handover rounds
- Bullying behaviour
- Management inaction
A poor culture at the leadership level can directly affect patient safety, as staff may feel unable to raise concerns or challenge unsafe practice.
Disproportionate impact on ethnic minority families
The inquiry identified systemic racism as a contributing factor to poorer maternal outcomes.
National data shows that Black women are nearly three times more likely to die during pregnancy or within six weeks of childbirth than white women. Asian women were 1.3 times more likely to die in the same period.
Women in the most deprived areas have twice the rate of maternal mortality due to long‑standing inequalities, including the effects of disadvantage, racism and discrimination.
Harmful stereotyping
Families described discriminatory assumptions that influenced care:
- Asian women being labelled as unable to cope with pain
- Black women perceived as having a higher pain tolerance
One mother described being made to feel like an “aggressive, angry Black woman” when asking for help during labour.
The inquiry also heard evidence that Muslim women from racialised minority communities were less likely to receive epidural pain relief. Some families reported hostility towards religious practices during hospital stays.
Discrimination was not limited to patients. Staff members from minority backgrounds were, in some cases, prevented from providing care based solely on ethnicity — further damaging team cohesion and trust.
Concerns about transparency and record-keeping
One of the most troubling themes to emerge was the handling of adverse outcomes.
Families described:
- Inaccurate or altered medical records
- Significant discrepancies between electronic and paper notes
- Delays or obstruction in accessing records
- Exclusion from trust-led investigations
In some cases, documentation appeared to have been amended years after the event.
Police investigations into maternity services at Nottingham University Hospitals NHS Trust have reportedly found that data in hundreds of cases was “most likely” deliberately erased.
Where transparency is lacking, families are often left with little option but to pursue legal action in order to understand what happened.
Supporting families affected by maternity failings
At Tees, our medical negligence solicitors have extensive experience supporting families affected by maternity and neonatal care failures.
We work closely with families to:
- Understand what happened
- Secure access to medical records
- Obtain independent expert evidence
- Pursue answers and accountability
- Seek compensation where appropriate
We recognise that no legal action can undo the loss of a child or the trauma of a negligent birth. However, a claim can help families access the truth, achieve financial security where ongoing care is required, and drive improvements in maternity services to prevent similar harm to others.
The need for urgent reform
In 2015, the UK government set out an ambition to halve stillbirths, neonatal deaths, and maternal deaths in England by 2030. Despite this pledge, improvements in maternity services have been slow. Our Freedom of Information report, which analysed NHS trust responses on patient safety and maternity care, underscored the ongoing challenges and persistent failings highlighted by the inquiry.
The latest evidence reveals that the maternity care system continues to fail the families it serves. Thousands have endured preventable harm, with women from ethnic minority backgrounds bearing a disproportionate burden of suffering. Racism, staffing failures, and institutional concealment continue to undermine care across NHS trusts.
Urgent reform remains the only path forward. Patient safety must be restored, and trust rebuilt through genuine accountability from healthcare leadership. Every woman deserves dignified, equitable care throughout her maternity experience. These fundamental failures cannot persist without consequence.
The time for incremental change has passed. Families deserve better, and the healthcare system must deliver it.
