National Maternity and Neonatal Investigation Uncovers NHS Failings in Early Findings

As both a mother of two and a solicitor who has represented families in maternity care scandals, including those at the Thirlwall Inquiry, I occupy an unusual vantage point. I have seen what happens when maternity services fail, and not just on paper, but through the eyes of grieving parents. Yet, even with all that knowledge, or maybe because of that knowledge, when I gave birth I was frightened. I saw how overstretched staff were, with 12-hour shifts, constant pressure, and often no time for the basics.

In August 2025, the Health Secretary appointed Baroness Valerie Amos to chair the new National Maternity and Neonatal Investigation (NMNI), with a remit to examine systemic failures in maternity and neonatal services and to ensure “safe, high-quality and compassionate care” everywhere.

Even before it had properly begun, Baroness Amos’ early findings from the NMNI confirmed what some families have known for years: that maternity services delivered by the NHS are subject to ongoing inconsistencies and frequent failings.

What Were the Early Findings of the NMNI?

In an initial report published 9th December 2025, Baroness Amos did not mince words:

“I expected to hear experiences from families about where they had been let down by the care they had received […] but nothing prepared me for the scale of unacceptable care that women and families have received, and continue to receive.”

Her review points to issues heard “consistently” across trusts: women not being listened to; inadequate information to allow informed decisions; discrimination (especially against Black and Asian women, working class women, younger parents, and those with mental health needs); and inadequate ward conditions, including situations where women who had lost babies were placed on wards alongside newborns.

Baroness Amos called the total of 748 recommendations made over the past decade staggering and posed the question: with so many previous reviews, why is maternity and neonatal care still so dangerously inconsistent?

She concluded bluntly that it is “clear … that change is not only possible, but also necessary, and it is urgent”.

Leeds Teaching Hospitals NHS Trust

One of the trusts under urgent scrutiny is Leeds Teaching Hospitals NHS Trust. In mid-2025, the Care Quality Commission rated maternity services at both Leeds General Infirmary and St James’s University Hospital as “inadequate”, citing serious safety risks based on some alarming data.

Between 2019 and 2024, at least 56 babies and two mothers died under circumstances now described as “potentially avoidable”. The findings included chronic staff shortages, dirty or unsafe facilities, unsafe medicine storage, under-resourced neonatal units, and a pervasive “blame culture” that discouraged staff from raising legitimate concerns.

The pattern echoes what I saw in the Thirlwall Inquiry, which was set up to investigate the conditions at the Countess of Chester Hospital after former nurse Lucy Letby was convicted of murder and attempted murder of babies at the hospital’s neonatal care facility. This report shares with the Thirlwall Inquiry evidence of systemic neglect, silencing of concerns, and horrifying consequences for families. For those mothers and babies, and for the parents I represented, this is not abstract. It is real, it is tragic, and it is unacceptable.

These findings hit close to home for me. As a public inquiries solicitor who has represented families through neonatal deaths and catastrophic injuries, I have seen the long-term damage to lives caused by failures that could have been prevented. As a mother of two, I felt the deep instinctive trust you must place in hospital staff when I gave birth. At the time, I worried: were the staff too stretched? Were they under too much pressure? Could something go wrong simply because they didn’t have time for the basics?

And now, with the evidence from the Amos review, supported by the reports of serious failures in Leeds, I know those fears were not irrational.

Lessons That Must Be Learned

There are several important lessons that must be learned in order to improve the standards of care and minimise the risks to mothers and babies across NHS hospitals. There is no need to wait for the final report of the NMNI - these suggestions should be adopted as soon as possible to protect families from avoidable harm.

Honour ‘owning up’, not concealment

The “duty of candour” must be meaningful, not a box-ticking exercise. Families deserve honesty when things go wrong. Regulators, policymakers and hospital managers must commit to genuine transparency and accountability.

Listen to mothers and families

When a woman says something is wrong, staff must respond. Reports of reduced foetal movement, unexplained pain or fear are too often overlooked. Staff must not condescend, not dismiss, not ignore, but investigate. Experience, data and repeated failures show that mothers’ voices are often the earliest warning sign.

Address staffing levels and safe working conditions

Wards in Leeds, the trusts covered by the national review, and elsewhere are understaffed and overworked, which makes tragedies more likely. Safe maternity care depends on staff who have time, capacity and support to do the basics properly. Staff want to have the time to give proper care, and the midwives I have met have shown dedication and commitment to their work, but do not have the resources they need to do the best possible job.

Implement findings from reviews

With 748 recommendations made over the past decade, yet so many failures persisting, the NHS needs action and the funding to get it done. The findings of the Amos investigation must translate into tangible reforms, with real oversight, funded staffing and enforcement.

Put families at the heart of reform

The NMNI was set up precisely because bereaved and harmed families demanded justice and change. Their voices and their testimonies, including those I heard first-hand in courtrooms and inquiries, must drive every reform.

My Hope as a Solicitor and a Mother

Representing families at the Thirlwall Inquiry, and now witnessing national and local failings crystallised in the Amos review and the Leeds scandal, has strengthened my resolve. I believe in the law’s power to deliver justice. But what I want and what every parent deserves is safety, dignity, and trust at the start of their child’s life.

My hope now is that this deep, damning evidence becomes a turning point. That every mother giving birth, and every newborn baby, receives not just medical care but real care; not just procedures but compassion; not just statistics, but respect.

Because no parent should ever have to believe their voice will be ignored.

If you believe that you have evidence to give to the National Maternity and Neonatal Investigation, legal representation can help you to understand your role and enable you to contribute your perspective. The team at JMW has represented many individuals and families during this process, and can support you in making a contribution, or in seeking justice for failures that should have been avoided.