The future of England’s maternity system is at stake. In the next few weeks, two major reports on failing NHS care will be published: Donna Ockenden’s four-year investigation into Nottingham and Valerie Amos’s national investigation into maternity and neonatal services.
Improvement is desperately needed. Maternal deaths have risen by a fifth in a decade. Targets to halve the 2010 rates of stillbirths and neonatal deaths by 2025 have been missed. And two thirds of England’s maternity units are failing to meet required safety standards.
But there are questions about what lies ahead. Before he resigned on 14 May, Wes Streeting had ordered not just the Amos investigation, but also agreed to three further local probes. After the Nottingham investigation, due on 24 June, Ockenden will carry out in-depth reviews in Leeds and Sussex. And, in direct response to a joint investigation by the New Statesman and Channel 4 News, Streeting asked NHS England to examine aspects of maternity care in Oxford. While families in Sussex and Leeds have been assured their inquires will go ahead as planned, there appears to have been little progress in Oxford in seven months.
The government plans for Amos’s recommendations to supersede all that have come before. Multiple inquires have delivered more than 700 suggestions over the past decade. But there are questions over whether it should be the last word. Not only do bereaved families campaigning for safer maternity care argue that the national review has not gone far enough in its questioning, in letters sent to Streeting and other health officials, seen by the New Statesman, they claim it relied on existing, unreliable data to judge the depth and breadth of the problems in maternity care. With just weeks until publication, is the Amos investigation the answer to our broken system?
Many bereaved families – but certainly not all – were sceptical of the national investigation into maternity and neonatal services from the start. They recognised the good intention behind it. But they saw its approach as flawed: it relied on unreliable data. You cannot solve a problem if you don’t fully understand it. The government argues that maternity safety data used to inform policy is drawn from a wide set of independently produced, standardised sources and that this provides a “robust and reliable picture of outcomes, risks and inequalities across the system.”
Tom and Ewa Hender’s son, Aubrey, was stillborn in May 2022 at Birmingham City Hospital, part of Sandwell and West Birmingham NHS Trust (SWBT). They have been campaigning for a safer and more accountable maternity system nationwide ever since. They are part of the Maternity Safety Alliance, which is calling for a statutory public inquiry into maternity care nationwide. Both the MSA and the Henders wrote to senior health officials when families were first provided with details of the approach the national probe would take. “Good, national data on maternity harm does not currently exist,” Tom and Ewa argued. A review, therefore, of “existing material will inevitably reinforce current blind spots, not challenge them. If data is skewed, defensive or incomplete, then any conclusions drawn from it are likely to be flawed, irrespective of sincere intent.”
In particular, the Henders highlighted one vital measure of safety (and harm) in the maternity system: internal hospital reviews into maternity deaths, known as Perinatal Mortality Review Tools (PMRTs). These grade the care provided and aim to provide answers for bereaved parents about why their babies died. A PMRT examines whether care was safe and appropriate, or whether different care may have changed the outcome. But campaigners say that when hospitals are allowed to mark their own work, they’re not always honest about failings. (Hospitals are required to include one external person in their review teams in 60 per cent of cases.) For parents of stillborn babies, PMRTs are likely the only chance for a review of their baby’s death, as most stillbirths are not eligible for other, independent investigation routes. The government sees these reviews as an important mechanism to support local learning within hospitals.
Official figures suggest around one in five stillbirths and neonatal deaths could potentially have been avoided. But there is good reason to believe the real proportion could be much higher. In every area I have reported on for the New Statesman, there have been families whose internal hospital reviews did not accurately reflect the poor care they received. In Oxford, the initial internal investigation of the death of Alice Topping’s baby, Smokey, found “no issues identified with the care provided”. An independent investigation drew different conclusions to the trust, and made a series of recommendations based on factors it said had contributed to Smokey’s death. In official statistics, Smokey’s death is not recorded as one that could have potentially been avoided.
Nor is the death of the son of one of the Sussex mothers I spoke with. Her treatment, she said, was “rated as excellent” by local clinicians, but the family later won a five-figure legal settlement from University Hospitals Sussex after the trust accepted its care had fallen short of acceptable medical standards. The internal review failed to mention that she had reported her baby was moving less often than normal in the days leading up to his stillbirth, but was told to stay at home.
In Leeds, while an inquest concluded that “neglect by midwives” and a “number of gross failures of the most basic nature… directly contributed” to the death of baby Aliona Winser-Ramm, the initial, in-house draft hospital review found no issues with the care. Her parents, Fiona Winser-Ramm and Daniel Ramm, said the report contained dozens of factual inaccuracies. Three years later, following the inquest, the trust re-graded their care to reflect the coroner’s verdict. “Had we not been so involved, done our research, been ‘fortunate’ enough to get an inquest (as stillborn babies don’t)… there is absolutely no way that our case would have received those gradings,” Fiona told the New Statesman.
The problems with PMRTs appear to be nationwide. In April it emerged that SWBT would review all stillbirths that occurred in 2025. The announcement followed a Care Quality Commission inspection, carried out after the regulator raised separate safety concerns in 2024. This time, inspectors reported discrepancies between how the trust graded care in PMRTs and what had actually happened. While staff identified no care issues, inspectors found details within the reviews that didn’t support that conclusion. These included not arranging follow-up scans for babies whose growth appeared to be restricted, failing to carry out neonatal resuscitation appropriately and according to guidelines, and not testing for gestational diabetes when it was indicated.
If a whole year of reviews can be wrong at one trust, why not other years, or other trusts? At SWBT, problems pre-date 2025. An independent review of stillbirths in the Black Country in 2023 – which included SWBT – criticised how reviews of babies’ deaths were carried out. In April 2026, Aubrey Hender’s PMRT was conducted again. A new team of clinicians identified problems in the original process four years earlier in 2022 and changed the grading.
The Care Quality Commission has highlighted poor-quality internal reviews of babies’ deaths, too. In 2023, for example, it noted that North Middlesex University Hospital in London had “not been reporting care issues which may or likely had made a difference to the outcome for the baby or mother”. The following year, the CQC said that “there was a lack of actions and lessons learned following the death of every baby” at Leicester General Hospital. Darlington Memorial Hospital “did not identify the cause of each baby’s death by robustly and comprehensively reviewing each case and the quality of care provided”.
The body that oversees and analyses the data on maternity deaths is called MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK). It’s a coalition of university academics who carry out the work on behalf of government. It, too, acknowledges weaknesses in the system. In evidence provided to parliament in December 2023, the organisation said that “hospitals reviews” were “more positive” than the conclusions reached by independent and external confidential enquiry panels reviewing the same information. One such enquiry judged only three out of 66 internal hospital reviews it examined to be of “good” quality. Hospitals identified that improvements in care were required in 40 per cent of cases; the independent panel put that figure at between 76 and 78 per cent. Official data could be under-reporting failures in care by as much as a half. “I am yet to meet a family (nationally) who feels that their PMRT was accurate or truthful,” Fiona Winser-Ramm said. “Imagine what underestimates of the national data the already horrific MBRRACE data is actually presenting?”
It is difficult to provide a definitive, up-to-date picture. The enquiry mentioned above, while published in December 2023, examined data from 2019. Yet this is the most recent enquiry to directly compare the judgements made by hospitals with those of external professionals. The national programme lead for PMRT, professor Jenny Kurinczuk, told the New Statesman: “Without doubt there has been an improvement in both the proportion of deaths reviewed and their quality over time since. [But] that is not to say all reviews are of high quality – we know that they aren’t and there is without doubt more work to do.” Kurinczuk said she remained concerned about the number of reviews still carried out by a small group, despite advice against this. In 2024, 9 per cent of reviews into neonatal deaths and 6 per cent of stillbirths were carried out by fewer than four people.
Many families believe that while Baroness Amos’s final report may contain individual details that shock some people, it will likely say nothing that has not been said by other inquires before. And then what? Can an analysis succeed if it relies on the broken system it is trying to fix?
The bereaved and harmed families of Nottingham, Sussex and Leeds are hopeful they will get the answers they have long fought for and deserve. But what about the rest of the country? For some families outside these areas, only a full statutory public inquiry led by a judge can deliver the level of independence, rigour and public accountability this crisis demands. Such an inquiry would compel those who have overseen the system to provide evidence. Politicians, health officials, regulators and professionals would be witnesses, not put in charge of fixing the situation that some hold them responsible for creating.
A spokesperson for the Department of Health and Social Care said the government was “determined to get this right” and that their “deepest sympathies are with every family who has experienced the loss of a baby or a traumatic birth.” The Amos review, they said, would “bring together evidence from a wide range of independent sources, alongside findings and recommendations from previous reviews, to build the clearest possible picture of where care is falling short and where action is needed.”
The challenge for those in power has always been balancing the wishes of different families. While some want the accountability and justice that a statutory inquiry would bring, others argue we already know what is going wrong. It just needs a proper commitment to fixing it, and fixing it now.
Urgent action is the priority. Through the maternity taskforce, chaired by a new Secretary of State, the “focus is on driving urgent improvements in maternity and neonatal services and ensuring the recommendations from Baroness Amos’ review are acted on as quickly as possible,” a health spokesperson said. For his part, Wes Streeting did not rule a statutory public inquiry. Speaking in June 2025, he said that any recommendation on that would be “in no small part determined by the findings of the [Amos] rapid investigation”. But for now it does not appear to be on the cards.
[Further reading: This is not what Henry Nowak’s family wanted]
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