Tara Mewawalla
Live reporter

A complete overhaul of the maternity system is required because "it is not fit for the now and it is not fit for the future".

That is the opinion of the chair of the National Maternity and Neonatal Investigation, Baroness Valerie Amos.

Her review, published today, highlights a culture in which women’s voices are ignored and a system embedded with racism. Her eight recommendations to overhaul the system include appointing a maternity and neonatal commissioner to oversee change.

Maternity safety advocate and former reality TV star Louise Thompson said she thought the review's recommendations were a "starting point" to improve maternal safety, but that wider change is needed.

Some affected parents argue that a commissioner would centralise too much power in one person's hands and are advocating for a statutory public inquiry. Amos says this is not her "decision to make".

Alice Topping, whose daughter Smokey was stillborn in 2023, says "families have not got the answers they deserve".

Health Secretary James Murray did not set an exact date for appointing a commissioner, and when asked about the possibility of a statutory inquiry, said he was "not taking anything off the table".

We are bringing our coverage to an end now, but you can read more in our news story.

If you have been affected by any of these issues, a list of organisations that can help is available on the BBC Action Line. You can also call 0800 066 066.

Catherine Burns
Health correspondent

Baroness Amos’s big ideas about totally re-designing maternity care won’t happen overnight - but some actions she wants to start immediately.

The key one is for NHS trusts to urgently review their triage process - when women are assessed because they have a concern about their pregnancy.

The report describes women phoning hospitals because they were worried their baby wasn’t moving enough, and being told everything was "fine".

It says: “Nowhere was it more apparent that the voices of women, birthing people and families were ignored or dismissed, than in the triage process."

The report calls for a dedicated midwife answering calls and if patients are still worried, to be offered a face-to-face appointment.

Baroness Amos believes that if these services are improved, lives will be saved and harm will be avoided.

Kayla Palmer, from West Bromwich, lost her son Hendrix at the Midland Metropolitan University Hospital in Smethwick in 2024.

He was delivered by emergency caesarean on 26 December but died three days later after suffering a brain injury linked to oxygen deprivation around birth.

"If I went to another hospital, would they have done different? Would my boy be here?" the 23-year-old asks.

Palmer says she experienced delays in pain relief and at one point collapsed during labour while a midwife walked past her.

"I hope this taskforce becomes something good. And a very good outcome comes out of it as well. I can only hope," she says.

The review found that racism and discrimination is widespread at the Sandwell and West Birmingham Hospitals NHS Trust (SWBH), which runs the Smethwick hospital.

Chief executive Diane Wake said the trust was "deeply sorry" to those whose care "did not meet the standards they have the right to expect".

• Click here to learn more about Palmer's story

Rob Sissons & Ben Carr
BBC East Midlands

Jo Holland, from Leicestershire, tells the BBC that her family has been "forever changed" after the "unforgivable" stillbirth of her grandson at Leicester Royal Infirmary in 2022.

Baby Mason’s cause of death was recorded as pre-eclampsia - an investigation found there were multiple failings in his mother's care.

University Hospitals of Leicester NHS Trust, which runs the hospital, was one of 12 NHS trusts looked at in the government’s maternity review which called for “urgent reform”.

The 54-year-old says she fears change in maternity services is happening too slowly.

Julie Hogg, chief nurse at University Hospitals of Leicester NHS Trust, said “important progress” had been made to improve maternity and neonatal services, “including strengthening how we listen to families, increasing staffing, improving triage and introducing digital systems to support safer care”.

You can read more here.

Catherine Burns
Health correspondent

The way women give birth in England is changing. Earlier this month, I reported that a quarter of all babies are now born by emergency caesarean section.

Planned caesareans have increased too, but vaginal deliveries are falling.

The Royal College of Obstetricians and Gynaecologists, which represents maternity doctors, told us pressure on staff and operating theatres means the system is "really struggling" to meet the increased demand.

This report says maternity services have not responded to this shift, but evolved in "an unplanned, reactive and piecemeal way".

Baroness Amos says this requires a fundamental re-think of everything from staffing to hospital structures.

She wants a new national maternity and neonatal commissioner to report to Parliament and families every year.

Barry O'Connor
BBC News NI

While today’s publication focuses on NHS services in England, maternity systems in Wales and Northern Ireland have previously been examined. An independent review of Scotland's services will begin after the summer and will last nine months.

In February, a report into Welsh services found there are insufficient staffing levels to meet the rapid increase in caesarean births and induction of labour compromising safety.

And in Northern Ireland, an October 2024 review of services - prompted by the death of a baby - called for a system-wide overhaul.

Speaking to the BBC’s Good Morning Ulster programme the author of that report - Professor Mary Renfrew - says there is "phenomenal support" for the 2024 report.

"From where I am looking at the moment, there are some small steps forward," she says.

Prof Renfrew says it is “often the case” that maternity care and midwifery are “seen as low priority”.

"We can't say that is definitively the case, but the messaging is there from a number of different countries."

Catherine Burns
Health correspondent

We’ve been hearing from unhappy families who don’t think the inquiry explored the issues deeply enough - although many of them think a statutory public inquiry will.

Others point out that there are already almost 750 recommendations from previous maternity reviews, and so are calling for action right now - this theme has been coming up over and again.

The Royal College of Midwives says the government now “must act”.

Sarah Scobie, from health think tank Nuffield Trust says: “We still won’t see meaningful change until the national taskforce and new maternity commissioner get started on actioning the recommendations.”

Earlier Louise Thompson, a maternity advocate and former reality TV star, said it feels like "the issues are consistently just kicked into long grass".

Medical negligence lawyers Irwin Mitchell said: “This report has to be more than another warning about the state of maternity care.”

Baroness Amos herself gets this - the report acknowledges that change needs political will and pressure, along with a cultural shift.

Catherine Burns
Health correspondent

One central recommendation in the report is what Baroness Amos calls a "Modern Service Framework".

She wants the government in England to design a new system for maternity and neonatal services.

She wants this to happen within a year - and to start being rolled out within 18 months.

Amos points out that the challenges will change, so it will need to be re-designed over and again to reflect that.

The idea is to have a set of national standards that will take women from before pregnancy through to postnatal care.

Part of this would be re-thinking staffing rota patterns, to make sure there are always enough senior consultants and midwives on duty.

It would also involve checking existing units are the right size and layout to deliver safe care.

Image source, Getty Images

Chair of the Health and Social Care Select Committee Layla Moran says she will sit on a taskforce that the government is setting up to look at maternity care, following the publication of the review.

Moran tells BBC Radio Oxford she agrees with the review’s findings that maternity services need "proper government-level leadership", but believes the government has "underfunded" any necessary change.

She also says she gave birth at the John Radcliffe Hospital in Oxford during a heatwave, and that the hospital had the heating on at the time.

Oxford University Hospitals Foundation Trust told BBC Radio Oxford that it accepted failings in its care, apologised to staff for working in difficult and demanding circumstances, and will listen and be open about any progress it makes, and any still needed.

Pedro Jacob - whose daughter was stillborn in 2023 - was asked earlier on BBC Breakfast what his views are on a full public inquiry into England's maternity services.

It comes after Baroness Amos, who conducted the review, said there was no need for an inquiry at the moment.

Pedro says: "That's not the reason not to bring accountability, and truth and justice to all our children that died. There are 800 babies dying every year."

He says his daughter would have been three-years-old in September and instead she is "a box of ashes" because the system failed to listen when they asked for help.

He continues saying healthcare regulators and professional bodies were not looked at and are part of the problem.

"They are the people that are supposed to regulate and ensure patient safety, but they were deliberately, or not, kept away from this report."

He adds that it is a "moral failure" that so many babies are dying.

Speaking to BBC Breakfast, Alice Topping, who we heard from earlier, is asked whether she feels that the report is a step toward being heard.

Topping says that bereaved families "haven't been listened to" despite having to become "experts" in their children's deaths.

She says that the recommendations are "just a snapshot" and that without a full understanding it risks "embedding systemic failings".

She adds that this is why she is calling for a full public inquiry to "look at the full system", because "everyone deserves basic, safe care".

Parents who gave evidence to the National Maternity and Neonatal Investigation, are speaking to BBC Breakfast this morning.

Asked what brings her here today, Lauren Caulfield, whose daughter Grace died in the days before her birth, says she wants "children to stop dying".

On the review published today, Lauren says she is "absolutely not" satisfied, arguing that it is "fundamentally dangerous" to implement a maternity commissioner that she believes would not be "meaningfully independent".

Instead, like a number of others, she calls for a statutory public inquiry "to understand exactly what has gone wrong" and "who has been responsible".

Also speaking to BBC Breakfast are Gina and Peter Reeves, who are asked about the review's finding of racism "embedded throughout the maternity and neonatal system".

Gina explains that when she was giving birth to her son, who died, she "was told that I didn't look like I was in pain".

"I didn't scream, I didn't shout, but my whole body went into shock mode and nobody listened to me."

Peter says he is "not surprised" by the report's findings, but adds that "it's not just what, it's what we do next" - and urges politicians to come together in order to improve outcomes for families.

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Eleanor Lawrie
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Alice Topping gave evidence to the inquiry after her daughter Smokey was stillborn at Oxford’s John Radcliffe Hospital in 2023.

Towards the end of her pregnancy, she called the hospital 44 times in one day begging for a scan after her height bump dropped, a known high-risk factor for stillbirth.

An external investigation carried out by Maternity and Newborn Safety Investigations found parts of her care had not complied with national guidelines and that staff had failed to listen or act on her concerns.

Alice - like some other bereaved mothers - wanted Amos to call for a public inquiry so that senior figures at under-fire hospital trusts would be compelled to speak.

She says: “Victims have been failed over and over again by different regulators. We're talking about a complete normalisation of preventable harms and preventable deaths.

"It's unacceptable, and we feel the only way to really get to the bottom of this is a statutory judge-led public inquiry.

"Families have not got the answers they deserve. The truth has been hidden from them, and it cannot continue to be like this.”

• For context, Health Secretary James Murray says when it comes to a possible inquiry he is "not taking anything off the table", but Amos says her view is that one is not needed

Oxford University Hospitals says it “apologised unreservedly to the women, babies and families who suffered in our care, or whose experience caused them grief or distress.”

Catherine Burns
Health correspondent

Over the last ten years, we’ve seen several high-profile maternity safety reviews - and there are more to come.

Just last week, we were reporting on an investigation into avoidable harm at Nottingham University Hospitals NHS Trust.

Many of the themes we’re seeing today were highlighted in previous reports: not listening to women, a lack of accountability, toxic working cultures.

Now, Amos’s report says the challenge is not understanding the problems with maternity. For her, the issue is "the large volume and complexity of different recommendations, standards and improvement efforts, which collectively has not translated into clear improvements".

She argues that there’s been progress immediately after previous reports, but that improvements haven’t been maintained. The report also says previous investigations have affected staff morale and confidence.

Catherine Burns
Health correspondent

Another all-too-familiar theme in this and other maternity reviews: racism.

This report says it is "embedded throughout the maternity and neonatal system" - and that this has profound implications for the care mothers and babies get.

The statistics back this up: black women in the UK are almost three times more likely to die in the year after pregnancy than white women. The risk is higher for Asian mums too.

The report heard from ethnic minority families about being left to wait for longer, getting slower responses or less friendly attitudes from staff.

Some felt staff thought they were exaggerating their pain levels.

The report talks about antisemitism with one family member being told by staff that "Jewish people are sneaky".

Staff said they were impacted by racism too, both from colleagues and patients.

Asked about the calls for a statutory public inquiry, Baroness Valerie Amos says "it's not my decision to make", but that she "absolutely" understands and respects why some families are calling for one.

She says her "personal view" is that statutory public inquiries take "such a long time", but that if her recommendations are implemented, "then in the future the kinds of justice that are being sought will be delivered".

"This could have a transformational impact on the system and we would not need a statutory public inquiry but that is a personal view."

That's the end of Amos's Today interview - we'll bring you more from the report shortly.

More now from Baroness Amos, who has also been speaking to BBC Radio 4's Today Programme.

She says that it was important that the report came up with a set of recommendations that can deliver change, and that the experiences of women were at the "heart of thinking" about what can be done to improve care.

Amos adds that the maternity commissioner role will report to families and Parliament, and that the position is about "oversight, accountability and driving the system".

A complete overhaul of the system is required because "it is not fit for the now and it is not fit for the future".

When asked about the experience of Emily Barley, whose baby died during labour, Amos says she is "extremely distressed and sorry" for what happened to her.

She adds that the she hopes that after Emily has seen the recommendations, she will see that the role is “not about concentrating power in the hands of one person”.

Murray is asked about calls from some affected parents for a statutory public inquiry into maternity care.

He says they are "not wrong to call for that" and that he can understand where "that feeling comes from very strongly".

He stresses that "some people favour a public inquiry, others have a different view", but says at this stage he is "not taking anything off the table".

In order to "drive accountability", the health secretary also says he will use the duty of candour which would be created in the Hillsborough Law to ensure that witnesses in upcoming reviews of maternity service failures can be forced to provide evidence.

In response to this interview, maternity advocate Louise Thompson says it feels like "the issues are consistently just kicked into long grass", and that without a firm date for when a commissioner would be appointed, "it just doesn't feel like the responsibility is there".

Asked for her advice to anyone who is pregnant, she says the key is to speak to friends, educate yourself, advocate for yourself, and remember that "you know your body best, so listen to your instincts".

Health Secretary James Murray is speaking to BBC Breakfast now, and he says the results of the report are "shocking but not actually surprising".

He says that the report outlines failings that the government already knew about, adding that NHS maternity services are "just not fit" and are failing too many women and families.

Louise Thompson then asks how long it will take to appoint the maternity commissioner role.

Murray says that over the next two weeks he will meet with a national task force to set out the scope for the role before getting it into legislation "as quickly as possible".

He does not set an exact date for appointing the position, he says, as he doesn't want to give a time frame he can't commit to.