First posted in June 2024. This post has been updated on August 21st 2025, and again after Valerie Ann Amos’ interim report was published on December 9th 2025.

These two paragraphs, highlighted in yellow, were written after the publication of the interim Amos report. Our comments on Amos’ report are at the end of the post. At the heart of our campaign, and of other such campaigns around the country, is the wish to make Maternity a healthier and happier experience for mothers and babies. We mourn those whose lives have been lost, we send sympathy to those who have been injured, physically, mentally or emotionally, to those caring for injured babies and children and those who have been bereaved. We also care for the staff who have been worn out in trying to make an under-resourced service as safe as it can be.

The people in government, in the top bureaucracy of the NHS and administering trusts, who callously left the service without resources and oversaw the damage as it was being done, must be removed from positions of authority.

Original post

We have been asked to publish this list of the key reports on Maternity issues in the NHS, so they are easy to find. Please let us know of any other reports you know about that we might have missed.

No government can pretend they don’t know about these reports. The campaign for better Maternity care is growing.

These are the many reports on the problems in Maternity care in the NHS. We have provided links to the actual reports and only a brief commentary on some of them.

1. Care Quality Commission 2022/23. There was an update in 2024. It is well worth a read. This is one part of it.”We are concerned that too many women are still not receiving the high-quality Maternity care they deserve. Of the 131 locations we inspected, almost half (47%) were rated as either requires improvement (36%) or inadequate (12%). At 12 locations, ratings for being well-led dropped by 2 ratings levels, and at 11 locations, ratings for being safe dropped by 2 levels.”

The CQC are also quoted in the BMJ report as saying, under the heading Acceptance of Shortfalls:

“On the basis of these findings the CQC has set out recommendations for NHS trusts and integrated careboards, including ensuring that they are collectingthe right demographic data and then using such datawhen reviewing and acting on patient safety incidents. The regulator has also called on NHSEngland to work with the Nursing and Midwifery Council and the Royal College of Obstetricians and Gynaecologists to “establish a minimum national standard for midwives delivering high dependency Maternity care.” It urged the Department of Health and Social Care to provide additional, ringfenced funding for Maternity services. Nicola Wise, CQC director of secondary and specialistcare, said, “Sadly, our latest maternity inspection programme has further evidenced the need for urgent action, with continued problems indicating that the failings uncovered in recent high profile investigations are not isolated to just a handful of individual trusts.” and “We cannot allow an acceptance of shortfalls thatare not tolerated in other services. Collectively, we must do more as a healthcare system. This starts with a robust focus on safety to ensure that poor care and preventable harm do not become normalised and that staff are supported to deliver the high quality care they want to provide for mothers and babies, today and in the future.”

2. Donna Ockendon Donna Ockendon produced the Shrewsury report and has gone on to do more. This interview with Donna Ockendon is useful too, especially the last section. This interview is also informative. Donna Ockendon is working on a report on a long review of Nottingham’s Maternity services. This video from Donna Ockendon explains some of it.

3. Bill Kirkup

4. Morecambe Bay,

5. Maternity Services in England House of Commons Health and Social Care Committee

6. Birth Trauma report, the debate in the House of Commons, and the published report, May 2024.

7. Report on the quality and safety of  Maternity services

8. Saving Babies’ Lives Report

9 2023/MBRRACE MBRRACE is a fundamentally important review published regularly.

10.http://www.keepthehortongeneral.org/docs/KTHG-Births-Dossier-v2024-2.pdf (Thanks to Jenny Shepherd for sharing)

Updated August 21st 2025

11. There is a summary of many reports on Maternity safety from the House of Commons Library here.

12. There was a worrying report from the CQC about Maternity services in Leeds General Hospital in 2024. There was also concern reported about the neonatal unit. A later 2025 report indicates some improvement, but still requires an improvement report.

13. The government has announced on June 23rd 2025, a rapid enquiry into Maternity Safety following meetings with bereaved parents. This is the announcement.

14. The Health Services Safety Investigations Body produced a summary in advance of the government’s proposed rapid enquiry. It can be found here.

15. Then there was the announcement of the name of the leader of the enquiry.

16 Meanwhile, the government will investigate ten Maternity services that are causing concern. Then there will be a system-wide investigation. This is the relevant document. The different responsibilities of the task force and the investigation have yet to be clarified. The bereaved parents, who met Wes Streeting, wanted an investigation by someone outside the NHS, which is why Baroness Amos was appointed as someone independent of the NHS. Baroness Amos is a Labour member of the House of Lords and has had many responsibilities, including being the first black woman cabinet member. Baroness Amos delivered a speech on women’s health, with a particular focus on black women’s health, in the House of Lords on International Women’s Day 2024.

17. This from the BBC about the recent coroner’s inquest into Ida Lock’s death sums up many of the reports.

18. Though not directly related to Maternity, this report on Women’s Health, published in Parliament in March 2025, is also important.

19. The particular risk to black mothers was reported in 2023 in Parliament. There are campaign groups on this issue, including https://themotherhoodgroup.org/, and FiveXMore have produced a detailed report and recommendations, well worth a read.

20. A report was published in The Lancet in May 2024 by Nicola Vousden, nicola.vousden@npeu.ox.ac.uk,∙ Kathryn Bunch, ∙ Sara Kenyon ∙ Jennifer J. Kurinczuk, ∙ Marian Knight, on the particular risk to black women reported this; “There were 801 maternal deaths in the UK between 2009 and 2019 (White: 70%, Asian: 13%, Black: 12%, Chinese/Other: 3%, Mixed: 2%). Using the routine data comparator (n = 3,519,931 maternities) to adjust for demographics, including social deprivation, women of Black ethnicity remained at significantly increased risk of maternal death compared with women of white ethnicity ( _{our emphasis} )(adjusted OR 2.43 (95% Confidence Interval 1.92–3.08)). The risk was greatest in women of Caribbean ethnicity (aOR 3.55 (2.30–5.48)). Among women of White ethnicity, risk of mortality increased as deprivation increased, but women of Black ethnicity had greater risk irrespective of deprivation. Using the UKOSS control comparator (n = 2210), after multiple adjustments including smoking, body mass index, and comorbidities, women of Black and Asian ethnicity remained at increased risk (aOR 3.13 (2.21–4.43) and 1.57 (1.16–2.12) respective 22. The Royal College of Gynaecology produced a position statement on poverty and women’s Health, including the impact on Maternity.“Poverty (lacking financial resources to meet needs) and deprivation (lacking many resources,including those that shape our health), can have a significant health impact across women’s lives.
This includes cutting lives short. Across the UK, women living in the most deprived areas have a life expectancy many years shorter than their least deprived counterparts.
In England, the disparity in female life expectancy between the most and least deprived areas is eight years, with those from the most deprived areas also living 20 years fewer in good general health.
Similar disparities are found in Scotland, Wales and Northern Ireland.

21. NHS England » Maternity and neonatal infrastructure review findings

This report on the buildings used for Maternity and Neonatal care is shocking. In some places, the birthing rooms are too small to accommodate emergency equipment. The very fabric of the service is substandard. Again, this is a government report, so the politicians know what’s going on and are letting it happen.

The Amos interim report, December 9th 2025. It is essential to point out that while some of these issues may well apply to Liverpool Women’s Hospital, these criticisms are not directed at it. There is good practice at Liverpool Women’s Hospital on some of the issues mentioned below. Liverpool Women’s Hospital is not one of the hospitals being studied in this report. But we fight for all Maternity services, not just Liverpool Women’s Hospital.

This is the complete PDF of the report from the Health Service Journal; this is the only link we can find.https://www.hsj.co.uk/download?ac=3072065

Valerie Ann Amos’ interim report includes these statements.

“..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 well-being.

While the issues I have heard about through this engagement have been extremely varied, there are a set of issues which I have heard about consistently. These include:

• a lack of communication and support from clinical teams and organisations
• women not being listened to or given the right information to make informed choices at critical moments of their care as risk profiles change
• women’s knowledge of their own bodies and important information essential to clinical decision making about their care, such as reduced fetal movement, sometimes being disregarded
• fathers and non-birthing partners feeling unsupported
• the desire for a more holistic approach to care across a woman’s maternity and postnatal journey, with maternity and neonatal teams working together to maximise good outcomes for women, their babies and families
• the impact of discrimination against women of colour, working-class women, women with mental health challenges and younger parents, leading to poorer outcomes
• a lack of empathy, care or apology, both as part of clinical care and after things have gone wrong, with women feeling blamed and guilty; a lack of recognition from staff when care is not delivered to the correct standards
• lack of family engagement in reviews of care and feedback of review reports
• an overly legalistic, adversarial approach when concerns or complaints are raised
• the failure of regulatory bodies to protect vulnerable women and families and the perception of health professionals and organisations ‘marking their own homework’
• failure to address poor behaviour, including the use of inappropriate language when communicating with women, families and non-birthing partners
• the length of time autopsy reports take to be produced, delaying families from being able to fully grieve for their children
• poor standards of basic care, such as lack of cleanliness, women and non-birthing partners not receiving meals, women not being helped to use the bathroom, and catheters not being checked or emptied
• women and families finding it difficult to access their medical notes (and notes being redacted or observations filled in at a later date)
• birth plans not being read or followed, leading to women not being cared for in the way they wanted or had agreed, as well as having to repeat their wishes multiple times
• women and families being placed in inappropriate spaces after loss or harm, for example, being put on wards with newborns after they have experienced a loss
• the impact of different philosophies around birth and pregnancy on women’s experience and ability to make informed choices
• having to work with multiple contacts when a baby dies, with issues arising from information not being shared sufficiently between different services
• the lack of recognition of, and support for, the long-term impact that these negative and traumatic experiences of services can have on families, for example: family breakdown; long-term impacts on the mental health of women and families; support for raising children with lifelong disabilities; bereavement care; participation in reviews or investigations; joint planning of complex care; and the need for neonatal unit accommodation and transition care
  I have also heard from some families about the high-quality, compassionate care they have received.

The staffing levels and the spaces in which the care is delivered are not mentioned. This is important; if ignored, problems will persist. Stephanie, one of our retired midwife campaigners, said, “You get one chance to deliver a baby safely. There are no reruns or repeats. The accoucher must get it right every time. To do so, the midwife must be supported by her colleagues, midwifery management and work within a fully safe environment. Alas, with the fragmentation of our NHS, top down draconian management, our mothers, their babies and our midwives are give short shift and they become the victims of often tragic circumstances. There is a woeful shortage of skilled midwives. Anyone can deliver a baby but it takes a skilled midwife to do so day in day out safely and with professional accountability.“

We are also concerned about the speed with which some of the hospital visits in the enquiry are planned. The report says

“For the remainder of December 2025 and in January 2026, the programme of site visits to hospital Trusts will continue. The Trusts to be visited are:

• Blackpool Teaching Hospitals Foundation NHS Trust

• University Hospitals of Leicester NHS Trust

• University Hospitals Sussex NHS Foundation Trust

• Sandwell and West Birmingham Hospitals NHS Trust

• University Hospitals of Morecambe Bay NHS Foundation Trust“

This doesn’t seem like an adequate time to gather anything except prepared comments from management. It is more than one hospital a week, and key reports will be published based on these snapshots. What else will be considered?The report does say” We have spoken with frontline staff, who have been open and frank about the pressures they are under, their experiences working in maternity and neonatal services and about the areas that require improvement”

And what will happen to managers who spill the beans about inadequate staffing, inadequate buildings, and the inadequacy of the Maternity tariff? Or criticism of Birthrate+, the tool used to determine staffing levels? Will they have whistleblower protection?

The visits are not the only work still to be done for this report. The author says

“I also want to make sure that we are hearing views from staff across the country and am finalising plans for how we will collect this evidence.

The enquiry will also meet a range of people from the NHS hierarchy. Will they also meet the unions and the campaigns?