The head of the national review of maternity services in England has voiced her shock at the widespread substandard care within the system.

Baroness Valerie Amos, who helms the National Maternity and Neonatal Investigation (NMNI), has criticized the slow pace of necessary reforms within maternity services, warning that this delay has led to deeply tragic outcomes.

In a revealing report, Baroness Amos shared her initial observations after visiting seven healthcare trusts, engaging with families, and consulting NHS staff.

She expressed her dismay, stating, “While I anticipated hearing about families’ disappointments with maternity and neonatal care, the sheer extent of the unacceptable treatment they have faced, and continue to face, was beyond what I imagined. These failures have had devastating consequences for infants and have significantly impacted the mental, physical, and emotional health of affected families.”

The report highlights that, over the past ten years, the NHS has compiled 748 recommendations aimed at improving maternity and neonatal care—a number Baroness Amos describes as “staggering.”

She added: ‘This naturally raises an important question: with so many thorough and far-reaching reviews already completed, why are we in England still struggling to provide safe, reliable maternity and neonatal care everywhere in the country?’

And the same problems seem to keep coming up, with the report highlighting a host 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.

Head of the national NHS review into maternity services in England, Baroness Valerie Amos, pictured in 2024, has said that ‘nothing prepared her for the scale of unacceptable care’

Elsewhere, the probe also heard of women who had lost babies being placed on wards with newborns, and 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’.

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.

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.’

The NMNI will focus on 12 NHS trusts, with findings published in 2026.

It comes after it emerged that a call for evidence, set to launch in November, was pushed back to January, with some site visits postponed until the new year.

But Baroness Amos said she has ‘full confidence’ she will complete the probe within the timeline and it will result in recommendations to ‘fundamental improvement’.

Health Secretary Wes Streeting, pictured last week, said the update from Baroness Amos ‘demonstrates that too many families have been let down’

Health Secretary Wes Streeting, who ordered the investigation in June, said the update from Baroness Amos ‘demonstrates that too many families have been let down, with devastating consequences’.

He said: ‘Bereaved and harmed families have shown extraordinary courage in coming forward to share their experiences.

‘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.’

Anne Kavanagh, a medical negligence lawyer at Irwin Mitchell, which represents hundreds of families across the country affected by maternity care failings, said: ‘High-profile maternity scandals stretching back decades from Morecambe Bay to failings at Shrewsbury and Telford hospitals and East Kent Hospital Trust have all pointed to widespread and deep-rooted problems nationally.

‘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.’

Leeds Teaching Hospitals has two maternity units – Leeds General Infirmary and St James’s University Hospital. More than 150 families have complained about their maternity care here

Mr Streeting is setting up the National Maternity and Neonatal Taskforce in the New Year which he will chair.

He added: ‘Harmed and bereaved families will remain at the heart of both the investigation and the response, to ensure no one has to suffer like this again.

‘Because every single preventable tragedy is one too many.’

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 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?’