Maternity services in Wales have long been subject to numerous safety reviews and escalation measures by the Welsh Government. A recent all-Wales assurance assessment of maternity and neonatal services, published in February 2026, has provided a comprehensive and up-to-date picture of maternity safety in Wales.
Whilst many families report receiving high-quality, safe, and compassionate maternity care across Wales, the assessment also paints a bleak picture of systemic issues around staff shortages, unsafe and inconsistent practices throughout all seven Health Boards, resulting in avoidable harm.
Coroners Call for Action
Coroners in Wales have been calling for changes to maternity and neonatal services for some time, with longstanding concerns raised regarding staffing levels, investigation processes, and subsequent learning.
Whilst stillbirth rates fell between 2014 and 2023 in Wales, these remain the highest in the UK. Wales also had the highest rate of neonatal deaths in the UK in 2023.
Two Prevention of Future Death (PFD) reports issued in 2025, following the deaths of both Liliwen Thomas and Etta-Lili Stockwell-Parry, highlighted a recurring disconnect between clinical observation and emergency action, with delayed escalation to senior consultants on multiple occasions, and failures in both maternal and fetal monitoring.
A PFD report is issued by a coroner following an inquest, where they believe action should be taken to prevent future deaths in similar circumstances. Its purpose is to compel Health Boards in Wales to review their staffing, training, and clinical oversight to ensure safer care for mothers and babies, and to encourage learning so that such events are not repeated.
Further detail on the PFD reports issued in these cases can be found here:
Liliwen Thomas — Prevention of Future Deaths Report
Etta-Lili Stockwell-Parry — Prevention of Future Deaths Report
A ‘Real-Time’ Review of Maternity and Neonatal Services in Wales
In contrast to the reviews conducted in England, the All-Wales Maternity and Neonatal Assessment was not a retrospective review. Instead it aimed to provide a real-time picture of the current state of NHS Wales maternity services. While the assessment recognised the commitment of staff to providing high-quality, safe care, and noted the benefit of freestanding midwife-led units, the findings also highlighted significant and ongoing systemic strain and inconsistent care quality across all Welsh Health Boards.
Report Highlights Significant Staffing Issues
The report identified an overwhelming staff shortage across all levels and staff groups. Current staffing levels and configurations do not meet the requirements of current population needs, nor the rapid increase in caesarean births and induction of labour, compromising the safety of both mother and baby.
It also detailed a clear imbalance in skill level, with a larger proportion of newly qualified midwives and fewer experienced midwives. The report notes an increasing demand on senior staff as a result, creating additional significant strain on the service.
“Postcode Lottery of Quality and Experience”
The assessment refers to a “postcode lottery of quality and experience,” with inconsistencies seen across a wide range of services including continuity of midwifery care, induction of labour, planned caesarean birth, triage, transitional care, and neonatal outreach care.
Some inconsistencies have been linked to geographical constraints and to outdated, inadequate facilities and equipment that no longer meet modern clinical standards. Neonatal services in South Wales remain particularly fragmented, with limited cot capacity causing delays for babies who need urgent specialist care. In October 2025, the South Wales network was at the highest escalation level for 18% of the month due to neonatal cot and maternal bed availability. Delays in transferring babies for urgent care can have significant consequences.
The Welsh Government’s Response
In response to the assurance assessment, the Welsh Government has implemented a three-year improvement programme to strengthen leadership with a national strategic oversight board, implement real-time safety monitoring systems, set up a national forum to share best practice, ensure birth discussions become routine, and develop a service specification for the induction of labour.
This is not an isolated picture. Concerns about maternity safety have been raised across the UK in recent years, including ongoing investigations in England such as the Donna Ockenden-led review of Leeds Teaching Hospitals and the National Maternity and Neonatal Investigation.
A further independent review into maternity and neonatal services at Nottingham University Hospitals NHS Trust is due to report on 24 June 2026. It is one of the largest maternity safety investigations in NHS history.
While each review is independent and reflects its own local findings, the recurring themes of staffing shortages, inconsistent care, and delayed escalation all point to a wider pattern within NHS maternity services that families across the UK are grappling with.
Kay Taylor, Partner in CL Medilaw’s Clinical Negligence team in Cardiff, Comments
“Sadly, we frequently see and are instructed to represent families at inquest in cases where failures in maternity and neonatal care have had devastating consequences. It should not be forgotten that at the heart of an inquest is always a grieving family who have to endure such an investigation in order to get answers and for lessons to be learnt.
It is disappointing to note that the issues and failures that we so often see are not in isolation, and in fact show a clear pattern of poor care and widespread issues in Wales. The recent All-Wales Assurance Assessment is a welcome step in the right direction for maternity and neonatal care in Wales, and we can only hope that the report is taken with the utmost severity and much-needed change is implemented at a critical time for maternity and neonatal services in Wales.”
Does This Affect Your Family?
Failures of the kind identified in this assessment — delayed escalation to senior consultants, inadequate monitoring during labour, inconsistent triage and care — are not only systemic concerns. For an affected individual or family, they can also form the basis of a maternity negligence claim.
If a baby has suffered a brain injury at birth, or a mother or baby has died as a result of substandard care, and you believe that delayed action, missed warning signs, or poor communication between clinical teams played a part, this may amount to clinical negligence.
A claim does not depend on whether a wider review has been published, as each case is assessed on its own merit. That said, reports like this one can help establish that the kind of failure you experienced reflects a recognised pattern of concern, rather than an isolated event.
How We Can Help
Specialist legal representation for women and families affected by substandard maternity and neonatal care is vital, particularly where a baby has suffered a significant brain injury at birth, or where they have died due to failures in maternity or neonatal care, resulting in an inquest.
Where avoidable harm has occurred during pregnancy or birth, Health Boards will often conduct their own investigation. While intended to take into account the suffering you have experienced, these investigations can seem clinical and lacking in real explanation or accountability.
We are routinely instructed to represent families at inquests and to pursue claims for damages where women and families have been subject to substandard NHS Wales maternity services, and where such care has contributed to the death of a loved one.
Our specialist birth injury team includes Kay Taylor, Laura Cook and Charlotte Moore, who are part of a 20+ strong team of legal experts specialising exclusively in birth injury claims. We regularly support families across the UK in bringing maternity and neonatal negligence claims.
If your family has been affected by maternity failings across Welsh Health Boards, we know how deeply distressing this experience can be. The impact of substandard maternity care is profound, often shaping a family’s financial and emotional future.
FAQs
Does this report affect my ability to make a claim about my own care in Wales?
No, every maternity negligence claim is assessed on its own individual facts, regardless of whether a wider review or assessment has been published. This report does not need to specifically reference your case for you to have a valid claim. What matters is whether the care you or your baby received fell below the standard expected.
What is a Prevention of Future Deaths (PFD) report, and how does it relate to my situation?
A PFD report is issued by a coroner following an inquest, where they believe action is needed to prevent similar deaths occurring in the future. It is sent to the relevant organisation, in these cases, Welsh Health Boards, and requires a formal response setting out what changes will be made. If your family has been through an inquest, or one is upcoming, a PFD report can form an important part of the wider picture, even though it is separate from a civil compensation claim.
Speak to Our Team Today
If you would like to speak with someone in confidence, our birth injury team is here to listen. We offer free, no-obligation consultations to help you understand your options and the support available.
We also work closely with charities including Peeps HIE, who support families affected by birth-related brain injury, and can point you toward additional sources of support alongside your legal options.
If you feel we may be able to help your family, please contact us on 0345 2410 154 or enquiries@clmedilaw.co.uk.
To arrange a free case review, complete our contact form and we’ll get in touch to arrange a conversation.
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