Maternity Safety in England: What National Investigations Show and What Families Need to Know
Informed by Barratts’ decades of specialist experience supporting families
Published: 11 December 2025
following interim reporting from the Amos Maternity Investigation
Understanding Maternity Safety in England: What National Investigations Reveal and Why Families’ Experiences Matter
For more than 30 years, we have supported families affected by serious failings in maternity and neonatal care across England. In that time, we have heard remarkably consistent experiences: parents who felt something was wrong but were not fully heard; delays in care; unanswered questions after traumatic events; and difficulties understanding what investigations meant for their family.
The interim findings from the National Maternity and Neonatal Investigation – widely covered by the BBC this week – bring these issues back into public focus. The accounts described in the report are deeply distressing: women left without basic support, delays in responding to warning signs, and discriminatory experiences among Black, Asian and working-class women.
Many families reading this may feel unsettled or unsure what this means for them personally. Others may be encountering this information for the first time.
This article brings together the key themes that appear across national investigations over the past decade. Our intention is not to overwhelm, but to help families see the bigger picture – and to understand how this week’s findings fit into what many parents have been raising quietly for years. Alison Brooks spoke at a recent conference with other clinical negligence solicitors and asked why lessons are still not learned from errors made. No-one seems to have the answer; we welcome reviews that might help to change this and avoid future negligence claims which are so devastating for affected families.
In Brief: Key Themes Seen Across National Maternity Investigations
- National investigations over more than 10 years – including Morecambe Bay, Shrewsbury & Telford, East Kent, Nottingham, Leeds and now the Amos Review – show recurring patterns of maternity safety concerns.
- Repeated themes include families not being listened to, escalation delays, inequalities in care, and inconsistent investigation processes.
- These are system-level issues, not reflections of any individual family’s actions.
- Many parents feel unsure before seeking help; that uncertainty is normal.
- Barratts offers a free, confidential conversation with a senior lawyer, with no pressure and no obligation.
- Our decades of experience means we can review records and documents to let you know if there may be a negligence claim and give you choices to decide what is best for you.
Why These Findings Matter for Families Today
National reviews, regulatory reports and inquiries highlight four recurring themes. Under each, we share insights based on our specialist experience supporting families.
Theme 1: Families Not Feeling Fully Heard
What National Investigations Consistently Report
Across multiple public reviews, parents describe raising concerns that were not fully acknowledged or acted upon. Examples come from inquiries such as Ockenden, East Kent, Nottingham Review and interim findings from the current National Maternity and Neonatal Investigation.
What Families Often Say
Parents frequently describe:
Sensing something was wrong but struggling to get attention
Not being taken seriously and instincts being undermined
Feeling that they were in the wrong when raising warnings
This emotional labour – having to self-advocate in vulnerable moments – is a common theme across public reports.
Why This Happens at System Level
Public inquiries often describe:
Communication breakdowns
Overstretched teams
Hesitancy to escalate concerns
Unclear roles during busy periods
These are system issues which need to be addressed.
Theme 2: Delays in Escalation and Missed Warning Signs
What Investigations Highlight
Reports including Shrewsbury & Telford, East Kent, MBRRACE maternal deaths and the Amos interim findings repeatedly describe challenges in recognising or acting on signs that required clinical escalation.
Common Questions Families Ask
Families often wonder:
“Should someone have noticed earlier?”
“Is this something that happens often?”
“Was it just a series of events that built up?”
We speak to many parents who are asking themselves these same questions and we help them to get the answers they need.
System Insight
Public investigations frequently refer to multiple small opportunities for escalation that accumulate over time, not one error. These failings are often influenced by staffing pressures, unclear decision pathways and conflicting priorities during busy periods.
Theme 3: Inequalities and Disparities in Maternity Experience
What National Reports Show
Reviews such as MBRRACE, East Kent and the Amos interim report describe differences in risk, treatment and listening across groups, with Black, Asian and working-class women reporting feeling dismissed or not fully believed.
How Families Describe This
Some parents describe feeling they had to push harder to be heard, which can be deeply exhausting. This is emotionally draining and can shape how safe or supported someone feels during maternity care.
Why This Matters
The inequalities spoken about in public investigations are systemic. This bias is often unconscious but it can shape how quickly concerns are acted upon. Recognising this is essential for understanding why experiences differ between families.
Theme 4: Investigations, Learning and Early-Warning Systems
What Families Often Need
Many families struggle with internal investigations that feel incomplete or unclear. However, public reports show that families reasonably expect:
Plain-language explanations
A clear timeline
A chance to ask questions
Sensitivity and transparency
How Systems Are Evolving
To improve safety and transparency, national bodies have introduced mechanisms such as:
MNSI (Maternity and Neonatal Safety Improvement Programme)
CQC maternity ratings
The MOSS early-warning system
HSIB/MNSI independent investigations
These are designed to give families reassurance, along with clear information about services and the standards they can reasonably expect.
Why These Patterns Keep Repeating: A System-Level View of Maternity Services
Across investigations and across our work supporting families four recurrent system pressures appear:
Communication gaps due to unclear roles, busy units, disrupted handovers
Cultural barriers leading to staff being afraid or unwilling to challenge decisions
Resource pressures, including staffing shortages and limited space
Fragmented learning so lessons remain local rather than embedded nationally
These challenges interact and compound each other. Understanding these patterns helps families see their experience not as an isolated event, but as part of broader patterns that independent reviews continue to highlight.
What Families Can Expect From a Maternity Investigation
Although every investigation is different, we believe that every family should be given 5 important things.
A clear chronological account of events
Identification of missed opportunities or system pressures
Assurance that concerns have been taken seriously
The chance to ask follow-up questions
Communication that is sensitive, honest, respectful and supportive
These are reasonable expectations whether or not a family chooses to seek professional support. If you have an experience that fell short of this standard, we are hear to listen.
Responding to These Reports
It is completely normal to feel overwhelmed, angry, confused or exhausted when reading reports like this. Repeated national findings can feel like confirmation of something deeply painful rather than reassurance that change is coming.
You do not need to have answers before speaking to someone.
You do not need to be sure something went wrong.
You do not need to have the language to describe what happened.
If you would like to talk privately and without pressure, our senior clinical negligence lawyers are here to listen and help you understand what steps – if any – you may wish to take. This is part of Barratts’ free initial conversation which we also offer to anyone who has a lawyer but still has concerns. You can call us on (0115) 931 51 71 to talk about your experience.
About the Author
Alison Brooks – Senior Partner, Clinical Negligence Specialist
- 35+ years’ experience supporting families affected by maternity and neonatal failings
- Legal 500 Hall of Fame
- AvMA Panel Member
- Law Society Clinical Negligence Panel Member
- APIL Fellow
- Specialist in maternal injury, birth trauma, delayed diagnosis and neonatal brain injury
Frequently Asked Questions
What does the Amos maternity investigation mean for families?
Amos highlights recurring concerns, including delays, communication problems and variation in basic care. As the report shows, these experiences are not isolated which may help families understand why their concerns feel familiar.
Are maternity safety problems happening across England?
National reports over more than a decade show similar patterns in multiple trusts. This does not mean all care is unsafe, but it does mean issues are widespread enough to require continued scrutiny.
How do I know if my maternity care fell short?
You do not need to make that judgement alone. Many families seek support because something “doesn’t feel right,” even if they are unsure why. Talking through the sequence of events with an experienced professional can help.
What should I expect from a maternity investigation?
Plain-language explanations, an opportunity to ask questions, respectful communication, and transparency about any missed opportunities or lessons learned.
Can I talk to someone even if I’m not sure something went wrong?
Yes. Many families contact us simply because they feel unsettled and want clarity. A confidential conversation can help you understand your options without commitment.
