Safety Watchdog Flags Ongoing Maternity Risks

The Health Services Safety Investigations Body (HSSIB) has released a preliminary report on maternity and neonatal safety in England. The exploratory review, carried out in spring 2025, highlighted concerns across the entire maternity and neonatal care pathway despite years of initiatives aimed at improvement.

The review comes after a series of high-profile scandals, including at Shrewsbury and Telford Hospital NHS Trust and Nottingham University Hospitals NHS Trust. The Shrewsbury inquiry, led by senior midwife Donna Ockenden, found that approximately 201 babies and nine mothers might have survived if they had received better care. The Nottingham review — also chaired by Ockenden — remains ongoing.

Safety Concerns and Baby Deaths

The HSSIB’s latest report indicates that safety concerns persist. Between October 2023 and June 2025, the board received 35 reports of safety concerns in maternity or neonatal services. These accounted for about 10% of all safety concerns received during that period. 

All cases involved “very serious harm,” including 10 baby deaths. Sixteen incidents occurred during labour, and 12 during the neonatal period. Most reports came from women or family members, although some were submitted by healthcare staff. 

Full Investigation Paused

The board had begun a scoping exercise to assess the need for a full investigation. However, the work was paused in June after the Secretary of State for Health and Social Care announced a national investigation into maternity and neonatal services, due to report in December 2025. 

Health Secretary Wes Streeting said that multiple reviews into local trusts had found “similar failings in compassionate care” after maternity service failures “that should never have happened”. He acknowledged “systemic” failings dating back more than 15 years and said families had been “gaslit” in their search for answers about their babies’ deaths. 

Although pausing its work, the HSSIB published its exploratory findings to support the national investigation. These were based on the 35 recent safety reports, meetings with 17 stakeholders, and a 2021 report by its precursor organisation, the Healthcare Safety Investigation Branch.

‘Compounded Harms’ to Families

The report identified 11 key themes. Progress had been made in maternity and neonatal outcomes, staffing levels, and governance, but disparities in care and outcomes persisted, partly due to health inequalities. 

The HSSIB found that maternity and neonatal systems were overly complex, with inconsistent collaboration and poor information sharing. Local governance often operated in isolation, and services struggled to identify and respond to clinical risks or to learn from the harms that happened to women and babies during pregnancy, labour, and birth.

“Patients experience compounded harm due to issues within the wider healthcare system,” the report concluded. It highlighted that local investigations, complaints processes, and legal proceedings such as inquests often caused additional harm. “Staff and trusts can lose sight of compassion during this process,” it said.

Four Areas for Further Review

The HSSIB recommended four areas for potential further investigation:

• National structures responsible for providing direction and oversight for maternity services.
• Local governance and its relationship to national bodies.
• Standards and approaches of local investigations when things go wrong.
• Education, training, and professional standards for clinicians.

Staff Experience Cumulative Stress

The report said that maternity and neonatal staff also experienced cumulative stress and harm. It raised concerns about the standards set in undergraduate and postgraduate education, and whether these could be met in practice, noting that too many recommendations were being made, with limited implementation. 

The HSSIB warned that multiple, high-profile maternity investigations and inquiries had eroded public confidence in maternity services. Some women were avoiding hospitals that had been the focus of national investigations, undermining recruitment and damaging staff morale. 

The report cited instances of midwives receiving death threats or being berated for working in “failing” services. 

Stakeholders had told the HSSIB that clinicians had also become more risk-averse for fear of blame, a defensive approach that “drives the behaviour that compounds the harm women and families experience.”

Dr Sheena Meredith is an established medical writer, editor, and consultant in healthcare communications, with extensive experience writing for medical professionals and the general public. She is qualified in medicine and in law and medical ethics.