Maternity units are ‘not fit for purpose’ with filthy, crumbling hospitals leaving mothers suffering unsafe and undignified care, a damning review has found.
And a lack of bereavement suites means families are often told devastating news in general waiting areas and forced to carry their dead babies past rows of happy new parents.
Pregnant women describe blood-stained toilets and showers, dirty beds and wards infested with insects and mould, as midwives warn that leaks, faulty equipment and other ‘safety hazards’ distract them from their work, while a lack of beds and cots distorts decision-making.
The National Maternity and Neonatal Investigation, chaired by Baroness Amos, has concluded women and babies are put at risk by a maternity system that is ‘not set up to deliver consistently safe, high-quality and compassionate care’.
It found the NHS continues to inflict harm, ignore women and cover-up mistakes despite years of reviews, inquiries and hundreds of previous recommendations.
The system must now be redesigned to improve safety and reflect the fact that mothers are increasingly older and more likely to require C-sections, it adds.
Lady Amos said: ‘Words cannot describe the pain, suffering and trauma I saw and heard time and time again when talking to women and families about their experiences of maternal and neonatal care in England.
‘Anticipation and joy turned into pain, distress and trauma.
Maternity units were found to be unfit for purpose by a damning new report. Pictured: Queen’s Medical Centre, which houses the maternity unit of Nottingham University Hospitals
Valerie Amos, author of the report, pictured here with Keir Starmer, said she witnessed indescribable trauma talking to women about their experiences with maternity units
‘There is absolutely no justification for the tragic cases of unsafe care and avoidable harm we continue to see in England. Nor is it acceptable that so many women and families experience a poor response and lack of accountability when something goes wrong.’
The review heard from 450 families, received 10,500 responses to a call for evidence, and gathered evidence from 9,000 staff. It also visited 12 NHS trusts. One woman told investigators: ‘The postnatal ward was dirty. My partner had to bring in Dettol. There was blood. It was awful.’
In another case, a parent said: ‘Can you imagine how I felt having to carry my dead son past all those happy parents with their babies… we should have been in a different part of the hospital.’
The Department of Health last night said it would appoint a commissioner in line with the report’s recommendations and pledged £41million to improve maternity safety.
The report comes less than a week after an inquiry led by senior midwife Donna Ockenden into Nottingham University Hospital found more than 500 mothers and babies suffered avoidable harm or died due to ‘deeply embedded systemic failures’ at the ‘toxic’ trust.
Chelsea Gowar, 26, has opened up about the ‘missed opportunities to save her baby’
Bonnie Thompson, pictured, died in November 2025
Missed chances to save our baby
By SHAUN WOOLLER
Bonnie Thompson died in November 2025 after ‘missed opportunities, poor communication and failures to listen’ to her parents’ concerns.
Her parents Chelsea Gowar, 26, and Oliver Thompson, 28, had been trying for a baby for two years with several miscarriages before they found out they were expecting Bonnie.
‘We were overjoyed – we thought this time everything would finally be different,’ said Miss Gowar, from Littlehampton, West Sussex.
But when she had severe headaches, visual disturbances and raised blood pressure six months into her pregnancy, staff at Worthing Hospital said it was anxiety – even though these can signal critical pre-eclampsia.
Over the next two weeks, she went back repeatedly saying her baby was moving less. A scan showed reduced blood flow to the baby, suggesting an issue with the placenta, but her case was not escalated.
‘Our concerns were repeatedly minimised,’ said Miss Gowar. ‘I knew something wasn’t right, but I was made to feel I was overreacting.’
When checks showed problems with Bonnie’s heartbeat, an emergency caesarean at Queen Alexandra Hospital in Portsmouth followed.
After six weeks, Bonnie was back in Worthing, where she died four days later, after receiving a blood transfusion. The hospital said: ‘We will fully support the coroner and are in contact with the family.’
