Welcoming a new baby into the world is one of life’s most joyful moments. For most families across England, it’s a time filled with hope, excitement and anticipation. It’s supposed to be a positive, life-changing experience.
But recent investigations into NHS maternity services have highlighted significant failings – cases where care fell short of what should have been expected, sometimes with tragic and devastating consequences, leaving families not only bereft but often unsupported in the aftermath.
Liberay Legal’s Head of Clinical Negligence, Carlos Lopez, shares his commentary on recent key reports, including the Ockenden reviews and the Baroness Amos investigation, and what they mean for the future of maternity services in England.
Carlos commented: “My aim isn’t to point fingers. It’s to understand the challenges, while also recognising the dedicated NHS staff who work hard every day to deliver better, safer care.”
The Ockenden Reviews: Shining a Light on Specific Trusts and Broader Lessons
The name Donna Ockenden has become closely associated with the push to improve maternity care across England.
Her first major review examined services at the Shrewsbury and Telford Hospital NHS Trust. Published in 2022, it was a thorough, independent investigation into hundreds of cases spanning many years. The findings were sobering – in many instances, better care could have changed outcomes for 201 babies and nine mothers.
The failings identified included problems with foetal monitoring, the management of complex pregnancies, a failure to listen to mothers and their families, and a culture where concerns weren’t always escalated or learned from effectively.
Importantly, the review didn’t just criticise. It laid out clear Immediate and Essential Actions for the whole of England, focusing on practical steps – safe staffing levels, proper training, strong leadership, robust incident investigation processes, and above all, genuinely listening to women and their families.
Many of those recommendations have guided improvements across NHS trusts. But failings persisted.
More recently, Donna Ockenden was commissioned to review services at Nottingham University Hospitals NHS Trust. This investigation examined over 2,500 cases and spoke to more than 800 members of staff.
The key findings make for difficult reading:
- Hundreds of potentially avoidable harms. Potentially avoidable adverse outcomes were identified in 444 maternity cases and 76 neonatal cases. Tragically, different care might have altered outcomes for around 260 babies – 155 deaths and 105 cases involving serious injuries including permanent brain damage. Overall, around 520 women and babies experienced potentially avoidable harm, including 156 babies and 6 mothers whose deaths might have been prevented.
- Systemic and long-standing failures. Deeply embedded issues were identified across the trust, with leaders aware of serious problems since at least 2010 but failing to act effectively. Problems included insufficient staffing and funding, incomplete mandatory training, poor foetal monitoring, failure to recognise deteriorating mothers or babies, delays in escalating to senior doctors, and inconsistent application of clinical guidelines.
- Failure to listen to families. Women and their families were often not believed or heard – particularly regarding concerns about reduced foetal movements, anxiety, or complications during pregnancy. This was most pronounced for vulnerable groups, with inadequate support for non-English speakers and documented reports of racist attitudes, including towards Black women.
- A toxic workplace culture. A bullying, intimidating culture persisted – described in the report as involving tribalism, normalised unprofessional behaviour, and a defensive “Nottingham way” mindset. Staff feared speaking up, leadership was unstable, and governance appeared focused on self-protection rather than patient safety.
- Failures in bereavement care. Post-death care was found to be inadequate in a number of cases, including serious failures around dignity, communication and mortuary processes.
The report echoes the findings from Shrewsbury in 2022 and includes 18 Immediate and Essential Actions for maternity services across England, covering safe staffing, family listening, better governance and clearer escalation processes.
The Baroness Amos Report: A National Picture
In 2025, following a series of concerning findings from trusts across England, the government commissioned a rapid national investigation chaired by Baroness Valerie Amos.
Her final report and recommendations, published in late June 2026, painted a broader picture of maternity and neonatal services across the country.
The key findings included:
- Too many women – particularly those from certain ethnic backgrounds – felt they weren’t listened to, heard, or believed. Racism and discrimination were identified as embedded issues requiring urgent action.
- Maternity triage systems are under significant strain, often functioning like an overstretched A&E for pregnant women.
- Persistent challenges remain around safe staffing, funding, training, and learning from serious incidents.
- In Baroness Amos’s own words, the system “is not set up to deliver consistently safe, high-quality and compassionate care” for everyone.
The review has prompted NHS England to develop a 10 Point Plan drawing from both the Amos and Ockenden recommendations, focused on the most urgent priorities.
The Wider State of Maternity Services in England
Maternity care in the NHS is under enormous pressure. Rising birth complexities, persistent staffing shortages, workforce burnout, and the long shadow of the COVID-19 pandemic have all taken their toll.
Report after report has pointed to deep-rooted inequalities. Black and Asian women continue to face disproportionately higher risks of poor outcomes. In some trusts, a culture of blame and defensiveness has actively hindered the ability to learn from mistakes and improve.
Carlos Lopez commented: “It’s important to recognise the incredible work happening every day. The vast majority of births in England result in healthy babies and happy families, thanks to committed midwives, doctors and support staff who go above and beyond. But the content of these reports is deeply troubling and demands urgent redress. Keeping mothers and babies safe has to be the priority.”
Many trusts have made genuine strides – improving listening practices, investing in training, and implementing Ockenden’s recommended actions. National efforts, including the Maternity and Neonatal Taskforce, signal a real commitment to long-term reform. But there is still significant work to be done.
Looking Ahead
These reports are not the end of the story. They are a call to action.
Families affected by poor maternity care deserve truth, answers and proper support. NHS staff deserve the resources, training and working environments that allow them to provide the excellent care they trained for. And every expectant parent deserves to feel safe, respected and heard throughout their care.
The NHS has a proud history of supporting millions of families through some of life’s most vulnerable moments. By learning honestly from these inquiries – tackling inequalities, investing in staff, and prioritising compassionate, evidence-based care – it is possible to build a maternity service that truly works for every family.
Progress is happening. With continued focus and genuine accountability, avoidable harm can be reduced significantly.
If you or a family member have been affected by poor maternity care and would like to understand your options, our clinical negligence team is here to help.
Contact us for a free, no-obligation conversation on 03330 115 105
