On 26 February 2026, Baroness Amos published her Interim Report as the chair of the Independent National Maternity and Neonatal Investigation.

The findings were harrowing, but unfortunately not surprising. In our position as clinical negligence solicitors, we see a broad spectrum of maternity and neonatal cases across the country. This experience allows us to identify recurrent themes that contribute to substandard care across maternity and neonatal care nationally.

Factors identified in the Interim Report

In her report, Baroness Amos identified six key contributing factors to the pressures on the maternity and neonatal system:

1. Capacity pressures

2. Culture and Leadership

3. Racism and Discrimination

4. Poor responses and lack of accountability when things go wrong

5. The quality of estates

6. Workforce

In a previous blog Suleikha Ali discussed racism and discrimination. I will be discussing capacity pressures and workforce issues as well as the quality of estates and provide an insight into these recurrent issues

Capacity pressures and workforce within maternity and neonatal care

In my experience as a clinical negligence solicitor in many of the cases I see, a significant contributing factor to substandard maternity and neonatal care is capacity pressures.

Busy wards and delivery units

Often antenatal and labour wards and delivery units are operating at full capacity, resulting in delays to admission to hospital, progression for induction, and delivery of the baby.

The failure to admit mothers to the relevant ward or triage promptly causes a delay in initial assessment. Consequently, early warning signs and issues are either missed or only appreciated when it is too late to prevent injury to mother or baby. As a result, these early issues left unmonitored, in cases we see, can often develop into emergency situations, when they could have been managed earlier and harm could have been avoided.

Similarly, the failure to deliver babies promptly, including the failure to perform planned inductions and caesarean sections on time can create emergency situations that are high risk, unfortunately in some cases leading to injury or even sadly death, which often could have been avoided if delivery had taken place on time.

Lack of capacity to provide emergency care

In a case against an East Midlands Trust in which we represented bereaved parents at Inquest, there were early signs of reduced fetal movements and an abnormal CTG reading, indicating that delivery was needed. Due to a lack of midwifery staff to assess and monitor our client and the lack of theatres available to perform an emergency caesarean section, delivery did not take place until nearly an hour and a half after the Coroner found it should have, and as a result, the baby was born in poor condition and was resuscitated upon birth. Tragically, the baby suffered hypoxia, severe blood loss and brain damage at birth, causing his death three days later.

The Coroner found that this baby would probably have survived if delivered earlier. However, the labour ward and delivery suite were very busy. The unit had been closed to new admissions earlier but a decision had been made to start allowing women back in again and that meant a number of women all needed to deliver their babies at the same time and so no operating theatre was free when it was finally realised that our client’s baby was in distress and needed to be delivered.

This case exemplifies the importance of acting on early warning signs so that the baby can be delivered promptly, and the devastating consequences that can occur if emergency situations are not recognised in time and delivery is delayed. It also highlights the importance of managing the capacity of the maternity unit to ensure that there is the capacity to provide the emergency care that may be needed.

Safe midwife staffing levels

Baroness Amos raised concerns in her interim report about safe midwife staffing levels. In the NHS, what is considered a safe level is calculated using the Birthrate Plus tool. However, even where units are ostensibly fully staffed according to Birthrate Plus, in reality, there are often gaps in the workforce as the tool includes staff that are not able to provide frontline care, such as managerial staff.

Baroness Amos highlights in her report that to fill staffing gaps, community midwives are being moved to work in delivery units in hospitals. The impact of this is that community midwives are being transferred into what is sometimes an unfamiliar environment onto hospital delivery units, where they do not necessarily possess the relevant training or expertise.

This is problematic as the lack of staff with relevant experience means that again early warning signs go unnoticed, opportunities for escalation are missed, and decisions for delivery are not identified soon enough. As discussed above, this can have devastating consequences causing avoidable harm.

Midwifes being moved to other departments

In our cases, we have heard evidence of midwives being moved from antenatal clinics to assist on the delivery suite, leaving the clinics without sufficient midwives to properly assess and escalate women coming in who need to be admitted.

This disrupts the care provided in the community or on other wards and causes delays in mothers being seen and problems being identified when they should have been. It can create a knock-on effect as in scenarios where mothers should be kept in and monitored, they are being discharged home to ease capacity, curtailing pre and post-natal care.

We understand that some of the midwives transferred onto delivery units have already finished one shift in the community or in the antenatal clinic and are more than likely tired and feeling overworked, which consequently can affect the quality of care that they are able to provide.

Delay in senior clinical review

Another issue that we see regularly is that families are not seen by a senior doctor, or not until it is too late. This means that care is predominantly provided by junior or less experienced members of staff who do not always have the knowledge, experience or if they do, the authority, to escalate concerns.

In a case where we acted against an East Midlands Trust, there was a delay in escalating concerns regarding an abnormal fetal heart rate. A junior doctor instructed continual monitoring, despite the abnormal reading, until a senior consultant attended over an hour later and escalated the situation, calling a category 1 caesarean. The lack of senior involvement created an emergency situation. This emphasises the importance of earlier involvement of senior clinicians.

Lack of time for full assessment

In many of our cases, staff do not carry out a full and thorough assessment of a mother in labour, often because they are having to care for a number of other women at the same time.

We have seen situations where staff have not reviewed the medical records so are unaware of existing medical history and potential risk factors in pregnancy, or of plans previously made and the reasons for those.

This is an issue Baroness Amos also raised in her interim report, where she said that clinical decisions are being made without access to patient notes and important information. In some cases, this can lead to women that are at high risk not accessing the care and treatment that they need to ensure that they have a safe pregnancy and delivery.

Patient's notes not being reviewed

In one of our client’s cases, there was no review of a patient’s notes when she was transferred onto the labour ward before treating her. As a result, the plan put in place to try to keep her and her baby safe was not followed and there was a delay in recognising that she was a high-risk pregnancy and needed continuous CTG monitoring.

When monitoring was finally started it showed obvious fetal distress and although then a decision to deliver was made it was too late to save her baby and he tragically died within an hour after delivery.

Had CTG monitoring been in place consistently, it is likely that the fetal distress would have been recognised promptly and delivery would have taken place sooner, in which case the baby would likely have survived.

I feel that this case demonstrates the importance of reviewing of medical records when pregnant women are seen in clinic, admitted to hospital or transferred between units.

The quality of estates for maternity and neonatal care

In her interim report, Baroness Amos also discussed the impact of the quality of estates and availability of resources on the maternity and neonatal care that is provided. A lack of available resources, missing or unreliable equipment can have a significant impact on care provided, particularly in emergency situations, if the right equipment is not available or valuable time is lost searching for relevant equipment.

Reliability and confidence in equipment

In a recent case of ours there were serious consequences when Trust staff felt equipment being used on a neonatal unit was not reliable. In our case, the neonatal team did not trust the diagnostic results produced by a blood gas testing machine, which had been in place for around nine years, to determine the treatment to provide sick and vulnerable babies.

This led to all tests being checked in the lab before the results were acted upon. The tests being repeated in the lab caused significant and life-threatening delays for our clients. However, this case also raises concerns as to how and why a unit was using testing it considered unreliable for so long when it was vital for the care of vulnerable babies.

We heard evidence that the decision to not rely on the testing was not Trust policy but an ad hoc decision which had not been properly communicated, but also that whilst the neonatal unit managers wanted to change the equipment they had not been able to do so as the Trust was bound into a long contract for the equipment. This is an example of the inefficient system in replacing equipment that Baroness Amos highlights in her report.

Action points

From the cases I have worked on and the issues discussed above; I consider that the following action points could lead to safer maternity care:

• Increased midwifery staffing to reduce the redeployment of staff across units
• Tools used to calculate staffing levels should specifically measure staff giving frontline care, and should include other staff such as managers separately, to gain a realistic picture of who will be providing care on the ward at that time
• Earlier involvement of senior clinicians in maternity care and assessment
• Compulsory review of a mother’s medical notes upon admission to hospital, on transfer between units and when new staff come on shift to ensure vital information is not missed in the handover
• Handovers of patients should include a detailed summary of risk factors, updated condition and relevant medical history at a minimum.
• Encourage and train clinicians to exercise professional curiosity so that gaps in in information are picked up
• Equipment should be easily accessible and located near point of use to minimise time taken to access equipment for treatment
• An inventory of available equipment and its location should be regularly performed
• Equipment should be regularly audited and where found to be unreliable or inefficient, there should be clear mechanisms to raise this and replace equipment
• Processes should be streamlined where possible to avoid repetition and duplication of testing to prevent unnecessary delays to treatment
• Clear reporting mechanisms in place for staff to escalate concerns if equipment is unreliable or inaccurate, with actionable responses

Baroness Amos’s Interim Report highlights significant issues that contribute to the pressure faced by maternity and neonatal services nationally. I have set out above just some examples where we have seen capacity pressures, workforce issues and quality of estates have a devastating impact on our clients, which emphasises why change and action is needed now.