Women were left to “bleed out” in bathrooms and babies suffered avoidable deaths in NHS maternity units, a damning review has found.
Changes within maternity care have been “too slow” despite being necessary and urgent, the head of an investigation into maternity care in England has said.
Valerie Amos, who is leading the national maternity and neonatal investigation (NMNI), has shared her initial findings after visiting seven trusts, talking with families and meeting NHS staff.
The report shows that the NHS has recorded a “staggering” 748 recommendations relating to maternity and neonatal care in the past decade.
Baroness Amos said she had expected to hear from families who had been “let down”, but that: “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 told BBC Radio 4’s Today programme on Tuesday of the horrific things women have gone through, saying: “Families talk about coming into hospital, being put in rooms, being left in those rooms for hours on end.
“Women are bleeding out in bathrooms… the poor basic care they receive, the lack of attention.”
She said women had said “time and time again” that they have not been listened to.
The review also found that hospital wards suffered from a lack of cleanliness and pregnant women went hungry after not receiving meals.
Emily Barley, whose daughter Beatrice died because of failings at Barnsley Hospital in 2022 and who co-founded the Maternity Safety Alliance, told the BBC her daughter died during labour at full term.
“She was a healthy baby and she died because of really basic failings in care and also cruelty by staff,” she said.
She said staff shrugged their shoulders, “instead of listening to me when I was raising concerns and then when I was begging for help, they were rolling their eyes.
“Instead of raising the alarm, near the end, the doctor was laughing. She was laughing at me, and that was while Beatrice was dying.”
She said the new review “beggars belief” and was “superficial”, with “no depth or detail”.
The report highlights a number of issues which Baroness Amos said she has “heard about consistently”.
These include women not being listened to, not being given the right information to make informed choices about their care, and discrimination against women of colour, working-class women, younger parents and women with mental health problems.
She added: “I do not understand why change has been so slow.
“It is clear from what I have already seen that change is not only possible, but also necessary and it is urgent.”
Elsewhere, the probe also heard of cases of women who had lost babies being placed on wards with newborns, or instances when concerns about reduced foetal movement were disregarded.
There were also reports of a lack of empathy from clinical teams when things go wrong, leading to women “feeling blamed and guilty”, the report said.
Regarding the experiences of staff, the review said: “We were told that staff have had rotten fruit thrown at them and that others have faced death threats after negative publicity and social media posts about the standard of maternity care in their unit.
Baroness Amos thanked families, some of whom have criticised the probe and called for a statutory public inquiry, for “constructive and honest feedback” as part of the investigation. The NMNI will focus on 12 NHS trusts, with findings published in 2026.
It comes after it emerged that a call for evidence for the investigation was set to launch in November, but has been pushed back to January, with some site visits also postponed until the new year.
Baroness Amos said she has “full confidence” she will complete the probe within the timelines set out and that it will result in recommendations for “fundamental improvement”.
Health secretary Wes Streeting, who ordered the probe in June, said the update from Baroness Amos “demonstrates that too many families have been let down, with devastating consequences”.
“Bereaved and harmed families have shown extraordinary courage in coming forward to share their experiences,” Mr Streeting said.
“What they have described is deeply distressing, and I can’t imagine how difficult it must be for them to relive these moments.
“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.”
Mr Streeting is setting up the National Maternity and Neonatal Taskforce in the new year, which he will chair.
Anne Kavanagh, a medical negligence lawyer at Irwin Mitchell, which represents hundreds of families across the country affected by maternity care failings, said: “Today’s announcement by Baroness Amos that nearly 750 recommendations relating to maternity and neonatal care have been made, many of which over the last decade, is truly staggering.
“For a number of years, we’ve maintained that many recommendations from previous reports and investigations haven’t been fully implemented, missing crucial opportunities to improve patient safety, learn from mistakes and prevent harm to patients in the first place, which is the best way to improve healthcare.
“Baroness Amos’s comments and initial findings are a sobering reminder of systemic failings and a critical opportunity to drive long-overdue improvements.”
Duncan Burton, chief nursing officer for England, said: “Baroness Amos’s independent investigation is a crucial step in driving meaningful change in maternity and neonatal care and we welcome her reflections and initial impressions.
“Whilst we have dedicated teams working across the country to improve services, we must do more to ensure that every woman and baby receives the safe, compassionate care they deserve. We will continue to work with colleagues across the NHS to address the issues raised.
“I want to reassure women and families that staff are continuing to work hard to provide the best possible care and want to do everything they can to support them – we would encourage them to talk to their midwives and maternity teams if they have any concerns.”
National Childbirth Trust chief executive Angela McConville said: “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?”
