Major maternity review finds systemic racism and unsafe care across NHS

On Tuesday, a sweeping investigation into English maternity services delivered a stark verdict: the NHS is broken in ways that have harmed hundreds of families and will continue to do so unless fundamentally rebuilt. Baroness Valerie Amos, who led the Independent National Maternity and Neonatal Investigation, spoke to 450 families and examined practices across 12 NHS trusts. What emerged was a portrait of a system where women are not listened to, where racism is woven into the fabric of care, and where the voices of those giving birth are routinely ignored or disbelieved—with consequences that have sometimes been fatal.

The report's language was unsparing. Maternity services are "not fit for the now and not fit for the future," it concluded. Health Secretary James Murray called it a "watershed moment" and pledged a comprehensive action plan by year's end. The investigation found that the system is "fragmented, overly complex and far too slow to learn." Patients reported not being able to give informed consent to medical procedures because they were not properly informed or heard. Throughout the services, the report identified what it termed "medical misogyny"—an embedded culture in which women's voices are systematically ignored, creating conditions where unsafe care becomes routine.

Racism and structural inequality, the report found, are not aberrations in the maternity system but are woven through it. The consequences for mothers and babies are profound. Patients described receiving unfair or unequal treatment that led to delays and unsafe care, sometimes with devastating outcomes. The report documented specific instances: a Muslim patient asked why she was wearing her headscarf, a Jewish patient told that "Jewish people are sneaky." There were accounts of racial slurs on NHS wards, Islamophobia, and antisemitism. Staff working in maternity services experienced racism too—from colleagues, from patients, and from families. They worked in poor-quality and sometimes dangerous clinical environments, often laboring through long shifts without breaks, in spaces without adequate rest facilities.

When things went wrong, families found themselves trapped in a system designed to protect itself. Internal NHS investigations were described by families as "marking their own homework." Some cases were never investigated at all because staff determined there had been no errors, even when harm had occurred. Baroness Amos said families should have the right to independent investigation when they disagree with internal findings. She spoke of hearing "heartbreaking cases" and described the "emotional toll and cost to families" as "indescribable."

The timing of the report underscored its urgency. It arrived less than a week after a separate inquiry into Nottingham University Hospitals NHS Trust found that more than 500 mothers and babies suffered avoidable harm or died due to "deeply embedded systemic failures" at what the inquiry called a "toxic" trust. That investigation was led by senior midwife Donna Ockenden and revealed the scale of harm that can accumulate when systems fail over time.

The government's response includes appointing the first-ever Maternity and Neonatal Commissioner, a role accountable to Parliament with a mandate to redesign services from the ground up. The commissioner will focus on establishing clear minimum national standards for safety and putting in place effective governance and accountability. Within a year, the government will introduce a national standard for triage—the process of assessing which patients need care most urgently. All maternity units must have dedicated triage staff trained in rapid assessment. NHS trust boards will be required to have clear oversight of how patients are triaged, with regular reviews of waiting times and performance.

The government is also rapidly expanding the Perinatal Equity and Anti-Discrimination Programme to every trust. The Health Secretary described the racism and discrimination documented in the report as "some of the starkest examples" found in the NHS. Both the General Medical Council and the Nursing and Midwifery Council must now treat racism, discrimination, and inequality as critical maternity safety issues. Shadow health secretary Stuart Andrew welcomed the proposals, saying that families should not have to keep proving the scale of harm they have experienced. "Their testimony must now lead to action," he said. What happens next will determine whether this moment becomes the turning point the report's language suggests it must be.