Unacceptable care and women left to ‘bleed out’ in bathrooms – maternity review

NHS maternity units are delivering “unacceptable care”, with some women left to “bleed out” in bathrooms and babies suffering avoidable deaths, according to the head of a review.

Baroness Valerie Amos, who is leading the National Maternity and Neonatal Investigation (NMNI), has spoken to more than 170 families across England, including those whose babies have died because of failings in care.

Some families have urged Health Secretary Wes Streeting to launch a statutory public inquiry, saying the current review does not go far enough.

Reflecting on the first three months of her investigation in a new report, Baroness Amos said “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 told BBC Radio 4’s Today programme on Tuesday of the horrific things women have gone through, saying: “Families talk about coming into hospital, being put in rooms, being left in those rooms for hours on end.

“Women are bleeding out in bathrooms… the poor basic care they receive, the lack of attention.”

She said women had said “time and time again” that they have not been listened to.

“There is something going on here that we need to get to the bottom of, and I hope that by the time I publish my final report in spring next year, that we will be able to identify some systemic changes that will make a difference,” she added.

Asked if there should be a statutory public inquiry, she said: “A decision on a statutory public inquiry is not for me to make.

“I agreed to chair this independent investigation on the basis of a set of terms of reference which are seeking urgent, systemic change.

“A statutory public inquiry is something which Secretary of State and others in government will consider.”

Baroness Amos also urged families to remember there is still “lots of good care out there” and “we have lots of staff who are doing a good job”.

Emily Barley, whose daughter Beatrice died because of failings at Barnsley Hospital in 2022 and co-founded the Maternity Safety Alliance, told the BBC her daughter died during labour at full term.

“She was a healthy baby and she died because of really basic failings in care and also cruelty by staff,” she said.

She said staff shrugged their shoulders, “instead of listening to me when I was raising concerns and then when I was begging for help, they were rolling their eyes.

“Instead of raising the alarm, near the end, the doctor was laughing. She was laughing at me, and that was while Beatrice was dying.”

She said the new review “beggars belief” and was “superficial”, with “no depth or detail”.

She added: “And what’s really scary is that this is now planned to supersede the recommendations and actions from investigations that actually were robust and thorough, and it just shouldn’t be happening.”

Ms Barley said Baroness Amos is “describing poor experiences and poor care” but “she’s talking about our children who were killed and other children who were horrifically injured, with life-changing, really serious brain injuries. And this kind of language is just minimising what’s happening”.

The report shows that the NHS has recorded 748 recommendations relating to maternity and neonatal care in the past decade.

Baroness Amos described this as “staggering” in her report, adding: “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?”

The report also detailed discrimination against women of colour, working-class women, younger parents and women with mental health problems.

Regarding the experiences of staff, the review said: “We were told that staff have had rotten fruit thrown at them and that others have faced death threats after negative publicity and social media posts about the standard of maternity care in their unit.

“We were told that negative publicity about a unit can make delivering high quality care all the more difficult.”

Mr Streeting, who ordered the probe in June, said the update from Baroness Amos “demonstrates that too many families have been let down, with devastating consequences”.

“Bereaved and harmed families have shown extraordinary courage in coming forward to share their experiences,” Mr Streeting said.

“What they have described is deeply distressing, and I can’t imagine how difficult it must be for them to relive these moments.

“I know that NHS staff are dedicated professionals who want the best for mothers and babies, and that the vast majority of births are safe, but the systemic failures causing preventable tragedies cannot be ignored.”

Mr Streeting is setting up the National Maternity and Neonatal Taskforce in the New Year, which he will chair.

James Titcombe, whose baby son Joshua died because of hospital errors, told the Press Association: “The issues highlighted today are not new – they reflect long-standing problems we’ve known about for years, yet sadly previous efforts to deliver lasting change have fallen short.

“The Amos review must now deliver a diagnosis that truly tackles the root causes and sets out a path to fundamental reform – learning from why previous attempts to address systemic problems haven’t worked.

“This has clearly been a tough process – there is a lot of negativity from some families who are campaigning for a statutory public inquiry – but in my view, this review, and crucially the taskforce being established to turn its recommendations into action, represents the best opportunity in a generation to finally put maternity services on a safer path.

“We now need action and change as soon as possible.”

Royal College of Midwives (RCM) chief executive, Gill Walton, said the report “paints a deeply distressing picture”.

She added: “Midwives are committed to safe, compassionate, woman-centred care but chronic understaffing and inadequate resources are undermining their ability to deliver it.

“The RCM has been raising concerns for years about these issues, the lack of urgency to improve maternity services and the absence of ringfenced funding for improvements.

“The Government already has the evidence it needs. It knows the scale of the challenge and the solutions that will make the biggest difference.”

Anne Kavanagh, an expert medical negligence lawyer at law firm Irwin Mitchell, which represents hundreds of families across the country affected by maternity care failings, said: “Baroness Amos’ comments and initial findings are a sobering reminder of systemic failings and a critical opportunity to drive long-overdue improvements.”