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Women were left to “bleed to death” in bathrooms and babies suffered avoidable deaths in NHS maternity units, a devastating review has found.
change within maternity care The head of the investigation said that despite being necessary and urgent, it has been done “very slowly”. motherhood Care is said in England.
Valerie Amos, who is leading the National Maternal and Newborn Screening (NMNI)has shared its initial findings after visiting seven truststalking with Family and meeting NHS Employee.
The report reveals the NHS has recorded a “shocking” 748 recommendations related to Maternity and Newborn Care In the last decade.
Baroness Amos said she expected to hear from families who were “disappointed”, but added: “Nothing prepared me for the scale of unacceptable care that women and families have received, and are receiving, with tragic consequences for their children and the impact on their mental, physical and emotional well-being.”
he told BBC Radio 4 Today Speaking on the program on Tuesday about the horrors the women endured, she said: “Families talk about coming to hospital, being put in rooms, being left in those rooms for hours.
“Women are bleeding in the bathroom…the poor basic care they receive, the lack of attention.”
He said the women have “repeatedly” said they have not been heard.
The review also found that hospital wards lacked cleanliness and pregnant women remained hungry due to lack of food.
Emily Barley, whose daughter Beatrice died in 2022 due to failings at Barnsley Hospital and who co-founded the Maternity Protection Alliance, told the BBC that her daughter died during delivery at full term.
“She was a healthy child and she died because of basic failures in care and the brutality of the staff,” he said.
She said the staff shrugged their shoulders, “Instead of listening to me when I expressed concerns and then asking for help, they rolled their eyes.
“Finally, instead of sounding the alarm, the doctor was laughing. She was laughing at me, and that’s when Beatrice was dying.”
He said the new review “beggars belief” and is “superficial”, with “no depth or detail”.
The report highlights a number of issues which Baroness Amos said she has “consistently heard about”.
These include not listening to women, not providing them with the right information to make informed choices about their care, and discrimination against women of color, working-class women, younger parents, and women with mental health problems.
He added, “I don’t understand why change is so slow.
“From what I have already seen, it is clear that change is not only possible, but necessary, and this is urgent.”
Elsewhere, the inquiry also heard cases of women who lost their babies and were placed in wards with newborns, or instances when concerns about low fetal movements were ignored.
There were also reports of a lack of empathy in clinical teams when things went wrong, leaving women “feeling guilty and guilty”, the report said.
Regarding staff experiences the review said: “We were told rotten fruit has been thrown at staff and others have faced death threats following negative publicity and social media posts about the standard of maternity care at their unit.
Baroness Amos thanked the families, some of whom have criticized the investigation, and called for a statutory public inquiry for “constructive and honest feedback” as part of the investigation. The NMNI will focus on 12 NHS trusts with findings published in 2026.
It comes after it was revealed that evidence seeking for the inquiry was due to begin in November but has been postponed until January, with some site visits also postponed until the New Year.
Baroness Amos said she was “completely confident” that the investigation would be completed within the stipulated timescale and that it would result in recommendations for “fundamental reform”.
Health Secretary Wes StreetingBaroness Amos’s update “shows that too many families have been let down with devastating consequences”, said Baroness Amos’ update, which ordered the inquiry in June.
“The bereaved and devastated families have shown extraordinary courage by coming forward to share their experiences,” Mr Streeting said.
“What he described is extremely tragic, and I can’t imagine how difficult it must be for him 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 that lead to preventable tragedies cannot be ignored.”
Mr Streeting is setting up a national maternal and newborn taskforce in the new year, which he will chair.
Anne Kavanagh is a medical negligence lawyer at Irwin Mitchell, representing hundreds of families across the country affected by maternity care failures, said: “Today’s announcement by Baroness Amos that almost 750 recommendations have been made relating to maternity and neonatal care, many of which have been made over the last decade, is truly staggering.
“For many years, we have maintained that many of the recommendations from previous reports and investigations have not been fully implemented, leading to missed important opportunities to improve patient safety, learn from mistakes and prevent harm to patients in the first place, which is the best way to improve health care.
“Baroness Amos’ comments and preliminary findings are a sobering reminder of systemic failings and an important opportunity to deliver long-overdue reforms.”
Duncan Burton, Chief Nursing Officer for England, said: “Baroness Amos’s independent investigation is an important step forward in driving meaningful change to maternity and neonatal care and we welcome her views and initial impressions.
“Although we have dedicated teams working across the country to improve services, we must do more to ensure that every woman and child gets the safe, compassionate care they deserve. We will continue to work with colleagues across the NHS to address the issues raised.
“I want to reassure women and families that staff are working hard to provide the best possible care and want to do everything they can to support them – we would encourage them to speak to our midwives and maternity teams if they have any concerns.”
Angela McConville, chief executive of the National Childbirth Trust, said: “While some women have safe, positive and supported experiences, inconsistency in care is unacceptable.
“None of this is new. As noted in the report, around 750 recommendations have already been made to improve maternal and newborn care.
“The question the investigation and maternity taskforce must now answer is simple: why hasn’t change happened?”