'They called about a missed scan after I lost my baby' - Blackpool maternity report reveals stark issues

A National Maternity and Neonatal Investigation has to be a ‘watershed’ moment after reviews into 12 hospital trusts, including Blackpool Teaching Hospitals NHS Foundation Trust, unearthed stark care issues.

The Amos Review, published today, has revealed that hundreds of families have been affected by maternity care failings, prompting medical negligence lawyers to demand recommendations be acted upon without delay to ensure patient safety is prioritised.

What did Blackpool families say?

The National Maternity and Neonatal Investigation team visited Blackpool Victoria Hospital on 9 and 10 December 2025 and on 26 January 2025 to speak to families and staff. Blackpool’s maternity services were rated ‘Requires Improvement’ by the CQC in August 2025 and the neonatal services were rated as ‘Good’ in 2019.

During the team’s visit to Blackpool, they encountered both positive and negative feedback from families and staff alike. The main issues raised by families were:

• Mixed messages coming from different teams and not being listened to, causing distress and feelings of being dismissed. One anonymous service user said: “I was obviously on edge thinking about infection… and instantly got very dismissed. I was made to feel a bit silly really.”
• Warning signs not being acted upon and symptoms such as pain being explained away as normal when families wanted clarity on what was happening. For those who experienced harm, this feeling was made worse when there was no clear acknowledgement or apology after things had gone wrong. One anonymous service user said: “I feel like, in those 12 hours, if I'd have been checked on, things might have been different, and I know I would have felt a lot better. So, by the time I went to delivery I was in an absolute state, so, I think that, for me, would be the main thing really.”
• Having ‘no choice’ due to repeated pressure to agree to interventions. One anonymous service user said: “Every time I’d said no, I’d been flat-out ignored and they’d just done what they wanted anyway.”
• Services feeling overstretched and understaffing impacting care, with ‘only two midwives for 22 beds’. One anonymous service user said: “Everything grinds to a halt at a weekend. If you go into the triage at the weekend, there’s one midwife and one healthcare assistant on duty. It’s wait until Monday”.
• Long waits for assessment, treatment, or support, particularly during labour or after birth. One anonymous service user said: “We got there at 9.00 in the morning… they just left us all day… they kept saying they didn’t have the staff for it right now.”
• Rarely seeing the same midwife or clinician more than once, leading to a feeling that staff didn’t understand their needs at a vulnerable time. One anonymous service user said: “I saw a different midwife every single appointment I had through my whole pregnancy. I never had the same person twice. So that was a bit unsettling.”
• Admin issues leading to distress - one woman said information was not logged correctly on the system after she lost her baby meaning she was contacted by a different member of staff reminding her about a scan, adding to her distress and trauma. She said: “Because they hadn't cancelled my scan, they rang me up to tell me I've missed my scan. That was just, like, such a punch in the stomach, like how it affected me. I was like, I can't believe you've just done this. Like you've just took... like, they obviously forgot to cancel it, but the impact that that has on you when someone then says, you know, basically tells me off, I like felt awful."
• Differences in being able to access services such as antenatal education, health visiting, and postnatal follow-ups based on a postcode lottery. One anonymous service user said: “Get antenatal classes, they get far better feeding support, all sorts. We get very, very limited. Purely because of the postcode, even though we all access the same hospital.”
• Surroundings leading to distress because of a lack of privacy, meaning people felt claustrophobic and leading to inappropriate settings - one woman was placed on a maternity ward following miscarriage. She said: “I ended up in the maternity ward in a bay with pictures of mothers with babies in their arms… I remember thinking, this is very strange to be in this environment, in this scenario.”

However, many families were quick to praise the services at Blackpool. Their main points included:

• Empathy for the strain staff were working under as they covered multiple roles, all whilst providing individual acts of kindness and remaining compassionate. One anonymous service user said: “You can have the best midwife, but if she’s overrun and too busy, she’s much more likely to not give you the care that you should be getting.”
• Staff making families feel listened to, believed and reassured. One anonymous service user said: “Every time we’ve gone in to get checked, it’s always been reiterated that we would much rather get you checked and you be happy rather than not call you.”
• Staff professionalism, kindness and emotional support during times of significant uncertainty and distress. One anonymous service user said: “Honestly, that neonatal experience for me was just brilliant. I just see them as angels.”

What did Blackpool staff say?

Overall, discussions with staff centred around the challenges of providing maternity and neonatal care in the area, with recurring issues highlighted including:

• Staffing numbers being based on the number of births rather than complexity of cases and staff having to move between areas to manage immediate safety risks. One anonymous staff member said: “If they're busy in the unit, you are asked to go and cover… we've had very good members of staff actually leave the trust because they have so much anxiety about going and working in an area… [they] don't feel safe in.”
• Patient discharge being slowed by staff shortages and the complexity of the community served by the Trust owing to high levels of deprivation, social challenges, and safeguarding concerns relating to domestic abuse, substance misuse, and late presentation to services. One anonymous staff member said: “It has become trickier. There's a lot of complex babies out there, a lot of complex families, a lot of social deprivation. So that's challenging.” Another said: “One of the highest nationally for safeguarding -- with significant social concerns who may well go into care.”
• Additional support required by groups who may face barriers to equitable care, including asylum seekers, refugees and people who do not speak English as a first language.
• ‘Relentless’ shifts causing exhaustion and impacting staff retention. One anonymous staff member said: “We would go 12, 13, 14 hours without a break… difficult sometimes even to go to the toilet.” Another said: “We recruit new midwives, but, unfortunately, we're struggling to retain them… they're shell shocked at how bad it can be, and we've lost so many newly qualified midwives recently.”

Despite these challenges, the National Maternity and Neonatal Investigation team said that they were ‘struck by a positive culture of encouraging trust, accountability, and shared learning and reflection’ in their conversations with Blackpool maternity and neonatal staff.

What did the team encounter in Blackpool?

The Trust serves a population that is more likely to be White and live in areas of higher deprivation than the national average. It also cares for more women who smoked in early pregnancy, are under 20, have had at least two previous live births, or have had a previous caesarean section.

The executive team described a community facing significant deprivation, poor health outcomes and social challenges, including poverty, insecure housing and complex trauma. They acknowledged the emotional impact on staff, many of whom share the same disadvantages as the communities they serve, and stressed that these realities must inform service planning and delivery.

Despite these challenges, staff remained committed to providing the best possible care while recognising that the service still faces ongoing issues, particularly staffing shortages. Improvement work included strengthened board oversight, enhanced incident reporting and the consolidation of more than 300 review actions into a single improvement plan.

Staffing vacancies across services increased reliance on temporary staff, placing additional pressure on permanent teams. Although some facilities were ageing and cramped, maternity and neonatal areas were welcoming, with efforts to create supportive environments.

Bereavement services were a notable strength, with the purpose-built Swan suite providing a private, dignified space developed in partnership with bereaved families and Stillbirth and Neonatal Death Charity (SANDS).

What does this mean for Blackpool?

Local deprivation and the wider challenges affecting people living and working in Blackpool continue to create significant pressures on the delivery of maternity and neonatal services.

Staff raised whistleblowing concerns about insufficient maternity staffing on shifts, and it was unclear whether senior clinical leaders had fully considered the wellbeing impact of moving staff between service areas to respond to changing acuity.

There was a clear difference of opinion between senior clinical leaders and frontline staff about whether staffing levels were safe. Reliance on agency staff increased pressure on permanent staff to support colleagues unfamiliar with local processes and reduced continuity of care for women and families.

Although the Trust is undertaking multiple recruitment campaigns, staff described ongoing difficulties in filling vacancies, meaning these pressures are likely to continue. Staff and Trust leaders remained committed to providing the best possible care.

However, persistent challenges, particularly midwifery staffing shortages and tensions between medical staff, continue to affect the Trust’s ability to deliver consistently safe services in a community with high levels of deprivation requiring a coordinated multi-agency and public health approach.

What has Blackpool Teaching Hospitals said?

Sam Westwell, Chief Nurse, Allied Health Professionals and Midwifery Officer at Blackpool Teaching Hospitals, said: “We recognise the importance of this national investigation and welcomed the opportunity to contribute to it.

“The report highlights areas where we need to do better, and we are taking those findings seriously. It also recognises positive aspects of care at Blackpool, including committed staff and welcoming services which are a clear strength.

“We have worked hard to improve staffing where needed, to strengthen support for colleagues, and continued improving care for families. We continue to listen, learn and respond and will now consider the full report carefully and work with women, families, staff and partners to make sure our care is the very best it can be.”