A‌ System Under Strain

A new report from the Health Services Safety Investigations body (HSSIB) reveals‍ ongoing​ and deeply concerning safety issues within England’s maternity⁢ and neonatal care system.The exploratory review, completed in spring 2025, underscores that despite years of efforts to improve care, notable risks remain ⁢for both ⁢mothers and newborns.

This ​latest assessment⁣ arrives in the wake of devastating scandals at Shrewsbury​ and Telford Hospital NHS Trust and Nottingham ⁢University Hospitals NHS ​Trust.The independant inquiry led ⁣by senior midwife Donna Ockenden‍ at Shrewsbury found that approximately 201 babies and nine mothers may have survived with improved care. The ongoing Ockenden review at Nottingham ‌continues to investigate similar allegations.

recent Safety Incidents and Data

Between ⁤October 2023 and June 2025, the HSSIB received 35 reports ​detailing serious safety‍ concerns ‍in maternity and neonatal​ services – representing roughly ⁣10% of all safety reports received during that period.These⁢ incidents all involved “very serious harm,” tragically including 10 baby deaths. Sixteen incidents occurred‌ during labor, and 12 within‌ the neonatal period. The majority of these reports originated directly from affected women and their families, though some were also⁤ submitted by⁤ healthcare⁢ staff.

Investigation Paused,⁤ But Concerns ‍Remain

The HSSIB had initiated a scoping exercise ‌to determine the⁤ need for a full investigation. However, this work was paused in ‍June 2025 following the announcement of a national investigation into maternity and neonatal services, expected to deliver​ its findings in December⁣ 2025. Health Secretary Wes Streeting acknowledged ‌”systemic”​ failings‍ spanning over 15 years⁢ and criticized⁤ a pattern of⁣ “gaslighting” experienced by families seeking answers about infant deaths.

Despite pausing its own full investigation, the HSSIB released its preliminary findings to‌ inform the national inquiry. This report draws on the​ 35 recent safety reports, input from ​17 stakeholders, and a 2021 report from its predecessor‌ organization, the Healthcare Safety‍ Investigation Branch.

Systemic Issues and⁢ ‘Compounded⁤ Harm’

The HSSIB identified⁢ 11 key‌ themes contributing to the ongoing safety concerns. While some progress has been made⁣ in areas like staffing and ⁤governance,disparities in‍ care persist,often ⁢linked to broader​ health ⁤inequalities. A central finding is that the maternity and neonatal systems are overly complex, characterized by inconsistent collaboration and⁣ inadequate information sharing. Local governance frequently operates in isolation, hindering ⁣the ability ‌to identify and address clinical risks and learn ⁢from past harms.

The report emphasizes that patients often experience “compounded harm” due to issues‍ within the wider healthcare‍ system. Local investigations,​ complaints processes, and legal proceedings – ‌such as inquests – can inflict additional trauma. The report notes ​a concerning tendency for compassion to be lost during ⁢these processes.

Areas for Further Scrutiny

The ⁤HSSIB has recommended focused investigation ⁤into ⁤four key areas:

• National structures overseeing maternity services
• The relationship between ⁣local‌ and​ national governance
• Standards for local investigations following adverse events
• Education, training, and professional standards for clinicians

Impact on Staff and Public Trust

The report also ‍highlights‍ the significant stress and harm ⁢experienced by maternity and neonatal staff.⁢ concerns‍ were raised ⁤about the adequacy of‍ undergraduate and postgraduate ‍training, and the⁣ limited implementation of existing recommendations. The repeated cycle of investigations and inquiries has eroded public confidence in maternity services,with some women‍ actively avoiding hospitals under scrutiny,impacting recruitment and ‌staff morale.

Disturbingly,the report ⁣details​ instances of midwives receiving death threats and facing abuse ⁤for working in services‍ labeled as ‌”failing.” Stakeholders⁢ reported a growing culture ⁤of risk aversion‌ among clinicians, driven by fear of ⁤blame, which ultimately exacerbates harm to women and ⁣families.