14 NHS Trusts Face Investigation over Maternity Failures

Baroness Amos has been appointed to make recommendations to improve care after avoidable baby deaths. She said:

“it is vital that the voices of mothers and families are at the heart of this investigation from the very beginning.”

“Their experiences – including both the fathers and non-birthing partners – will guide our work and shape the national recommendations we will publish.  We will pay particular attention to the inequalities faced by black and Asian women and by families from marginalised groups whose voices have too often been overlooked.”

“Our aims are to ensure the lived experiences of affected families are fully heard, to conduct and publish 14 local investigations of maternity and neonatal services and to develop recommendations informed by these that will drive improvements across maternity and neonatal services nationwide.”

The guidance published by the Department of Health and Social Care has set out clear aims of the investigation to crucially set up 1 set of recommendations.

In order to achieve this, the investigation will review;

• Lived experience of the families affected, including physical and mental impact and the social and economic costs.

• The quality and safety of maternity and neonatal services across the 14 Trusts to include care, delivery, variation between Trusts, compliance with national guidelines and the treatment of those with increased risks or additional needs.

• Understanding and managing recognised risks. It will involve understanding and managing recognised risks, considering clinical and managerial accountability, how it is established and access to it.   It will explore how it is communicated to families about what has happened and identify the role of regulatory bodies.

• Drivers and the impact of inequalities on babies and families from black and Asian backgrounds, deprived and marginalised groups.  It will explore racism, discrimination, lack of culturally sensitive care and language barriers and seek to understand how inequality and past experience contribute to a reluctance to seek care.

• The experience of staff and healthcare professionals by drawing on experiences of staff and professionals at all levels and at all stages of maternity and the neonatal care pathway and consider how best to achieve and support high-quality, safe, compassionate care.  It will encompass the role of culture and leadership and the impact of recruitment, retention, education, and training on delivery.

• The response of healthcare organisations, local and national healthcare systems, when things go wrong and harm occurs, and how healthcare investigations are undertaken and accountability established.

• Previous recommendations looking at previous recommendations in public enquiries and national investigations from 2015.

Opportunities and Barriers to Potential Improvements

Examples of good practice in the UK and comparable countries, focusing on investigating revenue and capital investment to understand the impact of equipment, financing facilities on safety and standards and opportunities for target investment.

The findings are due in December 2025 in the wake of the latest NHS maternity figures, which suggest maternity services are deteriorating.  The CQC has published that more than half of units no longer meet basic safety standards.

Recent scans have also identified a toxic culture, the risk of harm being normalised by failure to investigate, mistakes and silencing of whistleblowers and families.

GMC data shows more than 1 in 4 obstetrics and gynaecology trainees are hesitant to escalate to more senior colleagues.

There has to be a change in culture, attitude and willingness to learn and investigate because the voices of the affected families matter.

The impact is social, economic and very real. We eagerly await a clear set of actions.