Baroness Valerie Amos has delivered a scathing assessment of NHS maternity services, revealing that mothers and babies have suffered "unacceptable care" with "tragic consequences", including infant deaths.
The head of the national maternity and neonatal investigation released her initial findings on Tuesday after visiting seven hospital trusts and speaking with affected families.
She discovered a staggering 748 recommendations for improving maternity and neonatal care have been recorded over the past decade, yet problems persist across the country.
Lady Amos made clear that babies are still dying and harm continues to occur, raising urgent questions about why meaningful change has been so painfully slow despite years of warnings.
'Babies are still dying and harm continues to occur'
|GETTY
The investigation will ultimately examine 12 NHS trusts, with full findings expected in 2026. The investigation uncovered a troubling pattern of consistent failures affecting vulnerable women across the NHS.
Mothers repeatedly reported that medical staff simply weren't listening to them, and many weren't given proper information to make informed decisions about their care.
Perhaps most disturbingly, the report found evidence of discrimination targeting women of colour, working-class mothers, younger parents, and those struggling with mental health issues.
Some bereaved mothers who had lost their babies were placed on wards alongside newborns, adding unimaginable pain to their grief.
When women raised concerns about reduced foetal movement, these warnings were sometimes dismissed entirely.
Clinical teams also showed a lack of empathy when things went wrong, leaving mothers feeling blamed and guilty for outcomes beyond their control.
Baroness Amos wrote: "I expected to hear experiences from families about where they had been let down by the care they had received in maternity and neonatal units across the country, but 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 wellbeing."
She posed a fundamental question: "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?"
LATEST DEVELOPMENTS
Speaking to BBC Radio 4's Today programme, Lady Amos said: "Given that these harms continue to be done, given that babies continue to die, given that this is happening across the country, are there things that we should be doing to standardise the level of care across different trusts? Yes."
She continued: "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."
Health Secretary Wes Streeting, who commissioned the investigation back in June, acknowledged that Baroness Amos's update "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."
Streeting will personally chair a new national maternity and neonatal taskforce launching in the new year, promising that affected families will remain central to both the investigation and the response.
Chief nursing officer Duncan Burton offered reassurance that dedicated teams are working to improve services, urging women with concerns to speak with their midwives and maternity teams.
Medical negligence lawyer Anne Kavanagh from Irwin Mitchell, which represents hundreds of families affected by maternity care failings, pointed to a long history of problems.
She 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."
Kavanagh described the revelation of nearly 750 recommendations as "truly staggering".
The investigation will examine 12 NHS trusts
|GETTY
Angela McConville, chief executive of the National Childbirth Trust, acknowledged that some women do receive safe and positive care, but stressed the inconsistency remains unacceptable.
She said: "None of this is new. The question the investigation and the maternity taskforce must now answer is simple: why has change not happened?"
Our Standards: The GB News Editorial Charter