A national review by the Perinatal Mortality Review Tool reveals that more than one in five baby deaths in the UK in 2025 were potentially avoidable with better care. Investigating 4,110 deaths, the report identified maternity care issues in 93% of cases. Recurring failures include inadequate foetal growth surveillance and staffing shortages. The findings intensify scrutiny on providers like Oxford University Hospitals, which promised improvements following a June 2026 rapid review.
Findings of the 2025 perinatal review
- ▪An annual review conducted by the National Perinatal Epidemiology Unit at the University of Oxford collated investigations into the deaths of 4,110 babies in the UK in 2025.
- ▪The Perinatal Mortality Review Tool identified at least one issue with maternity care in 93% of the 4,110 baby deaths investigated in 2025.
- ▪The Perinatal Mortality Review Tool report found that more than one in five baby deaths in the UK in 2025 were potentially avoidable had different care been given.
Recurring issues in maternity care
- ▪The Perinatal Mortality Review Tool report identified recurring issues including surgical and social problems during pregnancy, maternal risk assessment, staffing during labour and birth, and thermal and respiratory management of newborn babies.
- ▪Professor Jenny Kurinczuk, director of the Perinatal Mortality Review Tool National Programme, stated that trend data highlights that the same issues with care are repeatedly identified, indicating where service improvement activities need to focus.
- ▪The Perinatal Mortality Review Tool report raised concerns that common care issues have remained similar over time, including late or absent booking for maternity care, inadequate foetal growth surveillance, and management of reduced foetal movements.
Scrutiny of Oxford University Hospitals
- ▪Following a rapid review into English maternity care led by Baroness Amos and published in June 2026, Oxford University Hospitals stated it would place the shared experiences at the heart of its service improvement plan.
- ▪Maternity services at Oxford University Hospitals faced intense scrutiny and criticism in recent years, with dozens of bereaved parents and harmed mothers in Oxfordshire criticizing the services.
Debatable claims
- ▪Local NHS reviews are sufficient to prevent recurring maternity care failures
- ▪Prioritizing patient feedback is the most effective way to reform failing maternity services
- ▪Clinical oversight failures are the primary cause of avoidable UK baby deaths
- ▪The high rate of care issues in baby deaths justifies national intervention in local NHS trusts
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