Bereaved parents speak out as report finds maternity care at Sandwell and West Birmingham NHS Trust 'deeply concerning'
The trust was one of 12 included in Baroness Amos' review
Last updated 30th Jun 2026
A report into maternity care at Sandwell and West Birmingham NHS Trust said the evidence collected "presents a deeply concerning picture".
In her nationwide maternity review that was published today (June 30), Baroness Amos said she is "concerned about safety for women, birthing people and babies" in Sandwell and West Birmingham.
These findings were not a surprise to Ewa and Tom Hender who's son - Aubrey- was stillborn at the old maternity unit at City Hospital in 2022.
The parents believe they were failed by the care they received and the trust has apologised to them.
They said many of the failings identified in the review are reflective of their experience.
"Everybody seems to have known that this was a problem," said Tom.
"We have been shouting - why has no one taken any action?
"At this stage, to wait another six months for a taskforce to make reccommendations is negligent.
"There needs to be action today."
Ewa said she felt ignored by staff at City Hospital prior to finding out baby Aubrey had no heartbeat.
"I had been mentioning that Aubrey's moves were getting weaker and fainter to anyone and everyone who I was interacting with."
She added: "The findings themselves just feel like they are repeating what we have been saying for the last four years.
"It highlights for us the fact that bereaved parents are not really listened to when to comes to issues with maternity care."
The couple said Baroness Amos' findings have unearthed what bereaved families have long already known.
Now, they are backing calls for a nationwide statutory inquiry into maternity services.
Tom said: "We feel let down by the final recommendations and we don't think that they go anywhere near far enough to address the concerns.
"What's needed is a statutory public inquiry."
Diane Wake, Group Chief Executive Officer at Sandwell and West Birmingham Hospitals NHS Trust said: “We offer our deepest apologies to Ewa and Tom Hender and our deepest sympathies on the loss of baby Aubrey.
"We are committed to providing safer care, better experiences, and a maternity service our community can have confidence in.
"We know trust has to be earned. We’re listening, we’re learning, and we’re making changes every day.
“The publication of the Independent National Maternity and Neonatal Investigation highlight deeply distressing experiences for women, babies, and families.
“We remain committed to being open, transparent and accountable as we continue to improve, and to providing a maternity service that women and families can have confidence in."
What did the Amos Review say about maternity care in Sandwell and West Birmingham?
Baroness Amos' investigation found evidence of widespread racism and discrimination at the trust and that some staff directed blame towards the women, birthing people and families they cared for when things went wrong.
Families said they were not believed, listened to, or taken seriously and many said their worries or fears were dismissed even when they raised clear concerns about pain, babies’ movements, labour not progressing, or their health getting worse.
Staff also described how the trust was seen as a "second-class unit" by some people in the region and that the neonatal network regarded Sandwell as a "disaster area" and used phrases such as another "Typical Sandwell Baby" when babies were transferred out for ongoing care.
In her report, Baroness Amos said: "Taking the evidence we collected, we are concerned about safety for women, birthing people and babies at this Trust."
The trust has apologised for the findings of the review.
In an open letter to the people of Sandwell and West Birmingham published today, Diane Wake said: "As we take time to fully reflect on Baroness Amos’ recommendations and the wider learning for our maternity and neonatal services, we want to address the concerns raised relating directly to our organisation.
"We want to begin by saying we are deeply sorry.
"We are sorry to the women, babies and families whose experiences of our maternity and neonatal services did not meet the standards they have the right to expect.
"The report highlights areas where our care fell short, and we recognise the lasting and profound impact this has had on those affected."
The letter continued: "We are particularly appalled by the accounts of racism and discrimination described within the report.
"It is unacceptable that any woman or family felt they were not listened to, respected or treated fairly because of who they are or where they come from.
"Serving a diverse community is a privilege, and we know that we must do more to ensure that every person receives safe, respectful, and equitable care.
"While the move to our new hospital has improved the physical environment for women and families, we recognise that buildings alone do not change culture.
"The report is clear that deeper cultural and organisational issues must be addressed, and we accept that responsibility.
"Our focus now is on rebuilding trust through our actions."
Diane Wake said those actions include a new Director of Midwifery and Head of Midwifery now being in place, the introduction of a zero-tolerance approach to discrimination of any kind, recruiting 25 additional midwives and the opening of a dedicated induction of labour suite for women who need support when labour doesn’t start naturally.
Off the back of Baroness Amos' review, the government said it is creating the UK’s first ever Maternity and Neonatal Commissioner who will co-chair a National Maternity and Neonatal Taskforce with the Secretary of State.