NHS Maternity Care Investigation: Calls for faster progress following baby deaths

BBC News has today reported on the progress of the Amos Report in its investigation into National Maternity and Neonatal Services.

Robert Miller, whose daughter Abigail died in a hospital at two days old following a delayed emergency Caesarean performed on her mother, Katie Fowler, knows this reality all too well. At the inquest, it was determined that Abigail’s life could have been prolonged had Katie been admitted to the hospital earlier. Mr Miller states: “It’s disappointing that she hasn’t managed to get any further with the report at this stage, but we’re pleased that she does seem to be making some progress.”

Alongside grieving parents, other agencies contributed to the investigation, including Sharon Allison, Partner at Ashtons Legal LLP and Chair of SCIL.

Investigation findings

This week, Baroness Amos, chair of the National Maternity and Neonatal Investigation, published initial findings.

• Systemic Failings & Safety: Services are heavily pressured, with inadequate staffing, poor skill mixes, and, in some cases, dangerous, outdated facilities leading to poor care standards.
• Discrimination and Inequality: There are significantly poorer outcomes from Muslim families, LGBTQ families and those with challenging mental health issues, all of which significantly contribute to poorer outcomes, especially for women of colour and those from deprived areas.
• Poor Culture and Leadership: The report found “poor relationships” between team members, with bullying and racist behaviour by senior clinicians often ignored by management.
• Defensive Responses to Harm: Families frequently experience a lack of compassion and transparency after safety incidents, with slow, inadequate investigations, and a “cover-up” culture.
• Previous Recommendations Ignored: Despite over 748 recommendations from previous reviews over the last decade, change has been too slow.

The problems run deep

The initial findings of the report paint a troubling picture of care for mothers and families across NHS maternity services.

Baroness Amos has repeatedly heard heartbreaking stories. Women say they felt blamed for their baby’s death and describe a lack of empathy, care, or apology when things went wrong.

Baroness Amos said: “Nothing prepared me for the scale of unacceptable care that women and families have received and continue to receive.”

These findings are not a surprise for Mr Miller as they represent his lived experience. He says: “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.”

What happens next

The investigation team says listening to women and families remains their top priority. They understand how desperately families need answers and final recommendations “as quickly as possible”. A spokesperson emphasised that every piece of information shared is being carefully considered: “All information shared with us is properly considered and helps in shaping our findings. Baroness Amos is grateful to all families for their time and contribution.”

There remains a call for evidence in place until 17 March 2026: Call for Evidence – National Maternity and Neonatal Investigation.

Amanda Cavanagh, Associate at Ashtons Legal Medical Negligence team, comments: “These are preventable tragedies and the interim findings of the Amos Review are a sad indictment of some of the current maternity services around the country. Many mothers receive excellent midwifery and obstetric care, but far too many don’t. There needs to be a permanent change to ensure avoidable injury and deaths do not occur”.

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