Maternity units across England are 'not fit for purpose,' according to a scathing review that details a catalogue of failures leading to unsafe and undignified care for mothers and babies. The National Maternity and Neonatal Investigation, led by Baroness Valerie Amos, concluded that the current system is failing to provide consistently safe, high-quality, and compassionate care, despite years of previous recommendations and inquiries.
The review uncovered instances of filthy conditions, including blood-stained toilets and showers, dirty beds, and wards infested with insects and mould. Midwives reported that leaks, faulty equipment, and other safety hazards distract from their duties, while shortages of beds and cots compromise decision-making. Furthermore, the lack of dedicated bereavement suites means that families receiving devastating news about their babies are often forced to do so in general waiting areas, sometimes having to walk past new parents celebrating their healthy newborns.
Baroness Amos stated that the pain, suffering, and trauma experienced by women and families were indescribable, with anticipation and joy too often turning into distress and trauma. She emphasized that there is no justification for the continued cases of unsafe care and avoidable harm, nor for the inadequate responses and lack of accountability when errors occur.
The investigation gathered evidence from 450 families, received over 10,500 responses to its call for evidence, and collected testimony from 9,000 healthcare staff. It also conducted site visits to 12 NHS trusts. One woman described her postnatal ward as 'awful,' noting that her partner had to bring in cleaning supplies due to the unsanitary conditions.
In response to the findings, the Department of Health announced it would appoint a commissioner to address the report's recommendations and has pledged £41 million to enhance maternity safety. This review follows closely on the heels of another inquiry led by senior midwife Donna Ockenden into Nottingham University Hospitals, which identified more than 500 cases of avoidable harm or death to mothers and babies due to 'deeply embedded systemic failures' within that trust.
The report also highlights the need to redesign the maternity system to account for changing demographics, noting that mothers are increasingly older and more likely to require Cesarean sections.