A comprehensive review has concluded that NHS maternity units in England are "not fit for purpose," citing a catalogue of serious failings that put mothers and babies at risk and result in unsafe and undignified care. The report, chaired by Baroness Valerie Amos, highlighted issues such as crumbling facilities, blood-stained showers, mould-infested wards, and a lack of bereavement suites, forcing families to receive devastating news in general waiting areas.
The National Maternity and Neonatal Investigation found that the NHS continues to inflict harm and cover up mistakes despite numerous previous reviews and recommendations. Baroness Amos stated that "words cannot describe the pain, suffering and trauma" witnessed when speaking with women and families about their experiences, emphasizing that there is "absolutely no justification" for the continued unsafe care and avoidable harm.
The review gathered evidence from 450 families, 10,500 responses to a call for evidence, and input from 9,000 staff members. It also visited 12 NHS trusts. Testimonials described unsanitary conditions, with one parent recounting having to clean blood from a ward themselves, and another expressing the trauma of carrying a deceased infant past new parents.
Systemic Failures and Calls for Redesign
The report advocates for a redesign of the maternity system to improve safety and better accommodate an aging population of mothers who are more likely to require interventions like C-sections. The investigation found that a lack of beds, faulty equipment, and other safety hazards distract midwives from their core duties, distorting decision-making processes.
This review follows closely on the heels of another inquiry led by senior midwife Donna Ockenden into Nottingham University Hospital. That inquiry uncovered over 500 instances where mothers and babies suffered avoidable harm or died due to "deeply embedded systemic failures" at the trust.
Case Study: Bonnie Thompson
One case highlighted involved Bonnie Thompson, who died in November 2025. Her parents, Chelsea Gowar and Oliver Thompson, reported missed opportunities, poor communication, and a failure by staff to heed their concerns during pregnancy. Gowar experienced symptoms indicative of pre-eclampsia, including severe headaches and visual disturbances, but was reportedly told it was anxiety. Despite scans showing reduced blood flow to the baby, her case was not escalated.
After issues with Bonnie's heartbeat were detected, an emergency C-section was performed. Bonnie was later readmitted to Worthing Hospital, where she died four days later after receiving a blood transfusion. The hospital stated it would fully support the coroner and was in contact with the family.
Government Response
In response to the findings, the Department of Health announced it would appoint a commissioner as recommended by the report and pledged £41 million to enhance maternity safety across the NHS.