National investigation finds maternity staff under “unsafe” pressure at Oxford hospitals
30/06/2026
Baroness Amos’ team heard from one staff member who described getting through shifts “by the skin of our teeth”
Maternity services within the Oxford University Hospitals NHS Foundation Trust are being hampered by unsafe staffing pressures, outdated facilities and families feeling they are not being listened to, according to a national investigation.
The findings are outlined in the final report and recommendations of the Independent National Maternity and Neonatal Investigation, which has been released today.
Across the country Baroness Amos found that the maternity and neonatal system is no longer fit to consistently deliver high-quality, compassionate care to every woman and family, and requires urgent reform to put safety at its centre, embed a focus on listening to women, and ensure anti-racist practice at every level.
Within the Oxford University Hospitals Trust investigators found staff were working under intense pressure, with some describing overnight staffing levels as unsafe and saying they were getting through shifts “by the skin of our teeth” rather than because enough staff were available.
The report, which examined services at the John Radcliffe Hospital in Oxford and the Horton General Hospital in Banbury, also found many families felt their concerns during pregnancy and childbirth were dismissed, with some saying warning signs were not acted upon until their condition became more serious.
Investigators highlighted significant problems with the ageing maternity unit at the John Radcliffe Hospital, describing the estate as “not fit for purpose”. They said cramped wards, outdated layouts and fire safety restrictions created delays moving patients between departments, affecting privacy, dignity and patient flow.
Families also raised concerns about hygiene, describing blood-stained toilets and clinical areas. Investigators said they observed a soiled toilet during their visit, with the trust apologising and acknowledging standards had fallen below what patients should expect.
The report questioned the Trust’s use of its ‘Oxford Growth Restriction Identification Programme’ (OxGRIP), under which all women are routinely offered a 36-week ultrasound scan. Investigators expressed concern that the approach departs from national NICE guidance and could reduce scanning capacity for women with a clinical need for additional scans.
Staff described a culture where challenging established practices was difficult, referring to questioning the prescribed ‘Oxford Way’ of working. Some also raised concerns about bullying, racism and misogyny, while 17 Freedom to Speak Up reports relating to maternity and neonatal services were recorded between spring 2024 and autumn 2025.
Despite the criticism, the investigation also highlighted areas of good practice. Families praised individual midwives and specialist bereavement teams for compassionate care, while investigators found the Horton General Hospital’s midwife-led unit to be clean, well organised and supported by a positive local team culture.
The Keep The Horton General group had raised concerns about the loss of full obstetric services in Banbury, but investigators didn’t undertake any work to test this.
The investigation concluded that Oxford University Hospitals faces sustained pressure from high demand, ageing facilities and staffing shortages. It said senior leaders did not fully appreciate the impact these operational challenges were having on frontline staff and warned that relationships between the trust and many families remained fractured.
The findings, along with those from 11 other Trusts in England have led Baroness Amos to make eight recommendations to redesign the maternity and neonatal system.
She said: “Women, babies and families deserve maternity and neonatal care that is safe, compassionate and equitable wherever they live. Too often, this Investigation heard that people were not listened to, that harm was repeated, and that families were left without clear answers or accountability when things went wrong.
“This report sets out practical action to change that. It recommends stronger national leadership, clearer accountability, better listening, safer service design, improved investigations, stronger teamworking and leadership, and investment in the buildings and digital systems where families receive care and deliver it.
“These recommendations must be implemented in full. They are designed to deliver lasting system change, strengthen accountability, and create a system that learns when harm occurs.”
In response to the Investigation Simon Crowther, the Trust’s Interim Chief Executive Officer said: “Today is about the women, babies and families whose lives have been changed by the care they received in our services.
“The report describes harm, distress and loss. It describes women and families who raised concerns about their own or their baby’s health, and who did not feel listened to or taken seriously. It describes confusing and inconsistent communication, and care that was not always safe, compassionate or individualised to them.
“For that, we are deeply sorry.
“We apologise unreservedly to the women, babies and families who suffered in our care, or whose experience caused them grief or distress. We failed them at some of the most important and vulnerable moments of their lives. We accept what families have told the investigation, the failings in care they describe in the report, and our responsibility to act.
“We want to thank the women and families who shared their experiences with Baroness Amos and her team, many of whom relived painful and traumatic events to do so. We know how much that will have taken. They came forward because they wanted to be heard, because they wanted answers, and because they wanted to spare other families the harm they suffered. We owe it to them to make sure their voices lead to lasting change.
“The report also reflects what many of our staff told the investigation. They described people who are committed to doing their best for women, babies and families, often in difficult and demanding circumstances. We are sorry for the toll this has taken on them, and we thank them for their dedication to the families in their care.
“We know that families’ trust and confidence in our maternity services have been badly damaged. We also know they will not be rebuilt by words alone, and that what matters now is what we do next.
“We will place the experiences shared with Baroness Amos and her team at the heart of our improvement plans. Women, families and staff will be directly involved in informing, shaping and delivering the changes we make. We will listen, act honestly, and be open about the progress we are making and the progress we still have to make.”
Published: by the Banbury FM News Team
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