The publication of the independent investigation into maternity and neonatal services in England led by Baroness Valerie Amos represents another pivotal moment for maternity and neonatal care in England.
Its conclusions are stark. The review finds that the current maternity system is no longer fit for purpose and calls for wide-ranging national reform. Its recommendations include stronger national oversight, improved accountability, independent investigations for families, better staffing and training, and a renewed focus on listening to women and tackling unacceptable inequalities in maternity care.
For many families affected by avoidable maternity harm, however, the report is likely to evoke mixed emotions.
There may be hope that this marks the beginning of meaningful and lasting change. Equally, there will be understandable frustration that so many of the findings echo those of previous investigations. For parents who have spent years searching for answers following the death of a baby or life-changing birth injury, today's report may feel less like a revelation and more like another acknowledgement of lessons that should already have been learned.
The Courage of Families Has Driven Change
Every major maternity review has one thing in common: it exists because families found the strength to speak.
Behind every statistic sits a family whose life changed in an instant. Parents who entered hospital anticipating one of the happiest days of their lives, only to leave grieving the loss of their baby or facing the lifelong consequences of a preventable injury.
Many have then endured years of unanswered questions, internal investigations that failed to address their concerns, and the emotional burden of reliving deeply traumatic events simply to establish what happened.
Any improvements that have been made across maternity care over recent years have not happened by chance. They have been driven by families who have shown extraordinary resilience in sharing their experiences and campaigning for safer care, often while living with unimaginable grief.
Their voices deserve not only to be heard but acted upon.
Standing on the Shoulders of Previous Reviews
The Amos Review does not begin a new conversation. Rather, it builds upon a growing body of evidence accumulated over many years.
The final report of the independent review led by Donna Ockenden into maternity services at the Nottingham University Hospitals NHS Trust represented one of the most significant examinations of maternity care ever undertaken in the NHS. Examining almost 2,500 families' experiences, it exposed repeated failures to listen to women, delays in recognising foetal compromise, poor multidisciplinary communication, inadequate staffing, weak governance and a culture that too often prioritised institutional priorities over patient safety.
The Ockenden Review resulted in 18 “Immediate and Essential Actions” that were intended not simply for one Trust, but for every maternity service across England.
Alongside the investigations into Morecambe Bay, East Kent, Nottingham and other NHS Trusts, the same themes have continued to emerge with troubling consistency.
- Women not being listened to.
- Concerns not being escalated.
- Poor communication between professionals.
- Failures to learn from previous incidents.
- Staff working under increasing pressure.
- Variation in the quality of care depending upon where a family happens to live.
- Failures to properly classify and investigate incidents.
Perhaps the most difficult aspect of reading the Amos Review is recognising how familiar these issues have become.
The NHS has not lacked recommendations. It has lacked consistent implementation.
Recognising the Professionals Who Continue to Deliver Outstanding Care
It is important that reports such as this do not unintentionally diminish the remarkable work carried out every day by maternity professionals across the country.
The overwhelming majority of midwives, obstetricians, neonatologists, anaesthetists, sonographers, maternity support workers and other members of multidisciplinary teams enter healthcare because they are committed to providing safe, compassionate care.
Every day, thousands of babies are delivered safely because of their skill, professionalism and dedication.
Many healthcare professionals themselves have voiced concerns about staffing shortages, increasing complexity of care, ageing infrastructure and rising demand for services. They too often experience the distress of working within systems that do not always provide the resources, staffing or support needed to deliver the standard of care they strive to achieve.
The failings identified in reports such as the Ockenden Report and the Amos Review are rarely the result of isolated individuals making poor decisions.
More often, they arise when dedicated professionals are working within systems that have become stretched, fragmented and unable to respond consistently to increasing pressures.
Improving maternity care therefore requires more than identifying individual errors. It requires sustained investment, effective leadership, better staffing, stronger governance and organisational cultures that support learning rather than blame.
Supporting healthcare professionals and improving patient safety are not competing objectives. They are entirely complementary.
Listening Must Become More Than a Recommendation
One of the strongest themes running through the Amos Review is the importance of listening.
Time and again, families describe raising concerns that were dismissed, minimised or insufficiently investigated. This is not a new finding.
It featured prominently within the investigations into East Kent, Morecambe Bay, Shrewsbury & Telford and more recently the findings relating to Nottingham University Hospitals.
Listening is often described as a simple concept.
In practice, it can be one of the most powerful patient safety interventions available.
Women know their own bodies. Parents notice when something does not feel right. Staff who feel empowered to raise concerns often identify risks before they develop into catastrophic outcomes.
Creating cultures in which every voice is heard may prove to be one of the most important reforms of all.
Turning Recommendations into Reality
Perhaps the greatest challenge now facing the NHS is not identifying what needs to change: that work has already been undertaken repeatedly.
The recommendations contained within the Amos Review sit alongside those of Donna Ockenden, Dr Bill Kirkup and numerous other independent investigations that have examined avoidable harm within maternity services.
The challenge is ensuring that those recommendations are implemented consistently across every maternity unit in England, regardless of geography, staffing pressures or organisational culture.
Families deserve confidence that lessons are not simply identified but embedded.
Healthcare professionals deserve to work in environments that enable them to provide the safe care they trained to deliver.
Looking Forward: A Statutory Public Inquiry?
No report, however comprehensive, can undo the grief experienced by families who have lost babies or whose children have suffered life-changing injuries.
Nor should the publication of another review detract from the dedication of the thousands of maternity professionals who continue to provide exceptional care under immense pressure every single day.
The Amos Review should therefore be seen not as an indictment of those professionals, but as a call to strengthen the systems within which they work.
Safe maternity care depends upon more than individual commitment. It requires sufficient staffing, effective leadership, a culture of openness, genuine accountability and the willingness to learn from mistakes before they are repeated.
Perhaps that is the most important message to emerge from today's report.
Families have been telling us for years that they want a Statutory Public Inquiry. All investigations up to this point have been voluntary and we know from Nottingham that many people in higher management refused to contribute to the review. A Statutory Public Inquiry will compel people to give evidence, require records and data to be disclosed and will get to the very root of the systemic problems in maternity and neonatal care.
A Statutory Public Inquiry can happen as recommendations from the Amos and Ockenden reports are enacted, so families know the lessons will finally be translated into lasting change.
A Note for Families
The publication of the Amos Review is likely to evoke a range of emotions for many people. For some, it may validate experiences that have gone unheard for many years. For others, particularly parents who have experienced the loss of a baby or a birth injury, reading the report may bring back painful memories or feelings of grief and trauma.
If you choose to read the review, please remember that you do not have to do so all at once. It is a detailed and, at times, distressing document. It is perfectly understandable if you need to pause, step away, or seek support.
If you have been affected by the issues discussed in this article or by your own experiences of maternity care, you may find it helpful to speak to someone you trust or to contact one of the organisations dedicated to supporting families following pregnancy loss, neonatal loss or birth trauma.
Support is available from organisations including:
- Sands, which supports anyone affected by the death of a baby before, during or shortly after birth.
- Tommy's, which provides information and support for those affected by pregnancy and baby loss, premature birth and pregnancy complications.
- Zephyr’s, which provides holistic and therapeutic support for bereaved families in the form of counselling, drop-in sessions, woodworking, yoga and wellbeing walks.
- The Birth Trauma Association, which offers support to parents experiencing the psychological effects of traumatic birth.
- Bliss, which supports families of babies born premature or sick and cared for in neonatal units.
- The Lullaby Trust, which provides bereavement support following the sudden and unexpected death of a baby or young child.
No family should have to navigate the lasting impact of avoidable harm or bereavement alone.
Mehmooda Duke, Founder and Partner from MDS, said "For families who have lost loved ones, until they see action and accountability, meaningful enforceable change being implemented and avoidable injuries and avoidable deaths of mums and babies coming to an end, these are just words. Whilst the systemic issues have been identified by the Amos Review in Leicester and around the country, the families that we represent feel strongly that it is only when there has been a Statutory Public Inquiry, that there will be true commitment to change "
Hannah Carr, Legal Director and Specialist Medical Negligence Solicitor from MDS, said “The Amos Review should not simply be remembered for the seriousness of its findings, but for the opportunity it presents. Families have shown extraordinary courage in sharing their experiences, and healthcare professionals have repeatedly highlighted the pressures they face. The challenge now is to ensure that the lessons identified over many years are translated into meaningful, lasting change. Every family deserves safe maternity care, and every healthcare professional deserves to work within a system that enables them to deliver it."
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