In a review of NHS maternity services led by Baroness Amos, the family said midwives were recording baby deaths as stillbirths to avoid coroner's inquests.[1][2] This system prevents families from getting full explanations about their babies' deaths, despite existing processes such as the Perinatal Mortality Review Tool and Maternity and Neonatal Safety Investigations.[1] The report describes frequent failures to provide safe care with discrimination and devastating consequences.[1] The maternal mortality rate in England rose from 8.8 to 12.8 deaths per 100,000 births in 2017–2019 versus 2022–2024.[1][3] Progress in reducing stillbirths, neonatal mortality, and preterm births slowed during the COVID-19 pandemic, but has recently slowed again.[1] Families called the review short and shallow, only diagnosing problems without making changes.[1] The problems are repeated at hospitals such as Morecambe Bay, Shrewsbury, Telford, East Kent and Leeds Teaching Hospitals.[1]