A national investigation into the deaths of mums and babies has looked at shocking cases of poor NHS care.

A national maternity probe chaired by Baroness Valerie Amos has outlined why mums and babies are still needlessly dying during childbirth. The inquiry outlined six factors that are still leading to poor NHS care despite numerous earlier inquiries into maternity scandals at trusts in the last decade.

When Katie Fowler, now 39, was in labour in January 2022, midwives who assessed her only over the phone missed warning signs she was suffering massive internal bleeding. They agreed she might instead be having a “panic attack” and encouraged her to stay at home.

Katie and her husband Rob Miller eventually took a taxi to the Royal Sussex County Hospital in Brighton, run by University Hospitals Sussex NHS Trust - one of those scrutinised in the national maternity investigation. Katie, from Hove, East Sussex, went into cardiac arrest as the taxi pulled up outside and surgeons had to perform a dramatic emergency C-section in the hospital lobby to save her life. Her baby, Abigail Fowler Miller, was resuscitated on waiting room chairs.

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Katie was woken from an induced coma nearly two days later to find out her daughter had unsurvivable injuries. Abigail died in her parents’ arms later that day, at 48 hours old. Katie said: “The last thing I remember is getting into the taxi to go to hospital and thinking I would be bringing home my baby girl. Instead I was woken up and told she was dying. It was the worst moment of my life.”

An inquest found Abigail’s would have survived if her mother had been called into hospital earlier. Katie believes maternity staff can be too stretched to treat mothers and babies as individuals. “You don’t listen to someone when you just see them as a bed number,” she said. “When I speak to other parents who have been through this, the cruelty of some of the comments made by staff is something that comes up again and again. The lack of compassion compounds your grief.”

Baroness Amos’s team has met with over 400 affected people and received input from over 8,000 people including mums, their relatives as well as NHS staff. She said: “It is clear from the meetings and conversations I have had with hundreds of women, families and staff members across the country, that maternity and neonatal services in England are failing too many women, babies, families and staff.”

The interim findings from the National Maternity and Neonatal Investigation come as Baroness Amos continues to draw up a series of national recommendations to improve maternity and neonatal services. However some families have said it does not have enough power and are demanding a full statutory public inquiry.

Katie says she feels “frustrated and disappointed” that the interim report has not identified why maternity services are struggling. She said: “There’s a lot of stuff we already knew about issues with workforce and leadership, but there is nothing in this report which explains what is causing mums and babies to be harmed on the scale that they are. Change is urgent and necessary but we are not any closer to that yet.”

She feels only a public inquiry – which would legally compel trusts to hand over information – will get to the bottom of what’s gone wrong. She added: “This is a scandal and it should be treated as one.”

In her foreword to the interim report, Baroness Amos said: “I have been asked many times during the course of this investigation what makes it different to those investigations and reviews that have gone before. The answer is that this investigation is national in scope and takes a whole system view… I see it as my purpose to understand the context and identify the urgent systemic issues that must be addressed.”

Wes Streeting will chair a new National Maternity and Neonatal Taskforce in the New Year which will be responsible for implementing the recommendations.

Emma Chambers, director of midwifery at UHSussex said: "We extend our deepest condolences to Ms Fowler and Mr Miller, and their wider families - we understand the loss of their daughter has been absolutely heartbreaking. We are all so sorry for their loss.

"Since the death of Abigail, we have made several improvements to the way we triage our mums, and we are monitoring how effective these changes are very closely. The Maternity Team at UHSussex works hard to provide the best care to all of the families who use our service, and we are always seeking to improve wherever we can."