Transparency, standards and a new commissioner – but does the maternity review go far enough?
The findings of Lady Amos’ review into maternity and neonatal services across England, which state the system is ultimately no longer fit for purpose, are unsurprising. The systemic failures and inadequacies of these services have been uncovered in several reports already, including Donna Ockenden’s review of the “toxic” Nottingham NHS trust published last week.
But what this report does offer are a set of recommendations for the government to implement. Amos states that if they were to be delivered in full then “the overall safety and quality of maternity and neonatal care in England will be materially and sustainably improved”. But how far do these recommendations go, and what will it take for them to be implemented?
A recurring theme across multiple maternity investigations has been the experience of bereaved and traumatised families being left in the dark, often having to fight for years to uncover the truth about what went wrong in their maternity and neonatal care. Many reviews have identified a “cover-up culture” within NHS trusts, where failures were minimised or concealed, leaving families without answers and undermining accountability.
One of the clearest examples is the case of Sarah and Jack Hawkins, whose daughter Harriet was stillborn in 2016. Nottingham university hospitals NHS trust initially told the parents Harriet’s death had been unavoidable. It was only after the couple fought for an independent external review that it was revealed Harriet’s death was due to failures at the trust.
One of the key recommendations of the Amos review seeks to address this issue directly. It proposes that, once an NHS trust has completed all its internal investigations, families who remain dissatisfied with the findings should have an automatic right to request the trust commissions an independent investigation into the case.
If implemented, this recommendation would represent a significant step towards greater transparency and accountability for families seeking answers. In Harriet’s case, had such a mechanism already existed, her parents would not have had to battle so hard to obtain an independent review and establish the truth about what happened to their daughter.
The report also calls for binding national standards, rather than just guidance, which is now used in some instances for aspects of maternity care. Failures within maternity triage, which essentially serves as A&E for pregnant women, were described as “deeply concerning” by the report. They have been severely understaffed and lacking physical space in order to adequately address the needs of pregnant women who may present with serious symptoms and conditions.
Currently, there’s national guidance that sets out what minimum staffing and space levels at these triage services should be. But the report goes further by calling for maternity triage to be formally designated as a safety-critical clinical environment with binding national standards.
The report also calls for a maternity commissioner, who will be instrumental in “providing the leadership and oversight needed to drive accountability and implementation of a redesigned maternity and neonatal system”.
In May, the Labour MP Michelle Welsh was appointed the government’s first maternity adviser. However, the implementation of a maternity commissioner, wholly independent from the government, will be a more concrete step to ensuring transparency and accountability across the country’s maternity services.
The report also has its limitations. The review does not shy away from identifying the systemic “racism, discrimination and structural inequalities embedded throughout the maternity and neonatal system across England”. That black mothers are almost three times more likely to die in childbirth than their white counterparts, while black babies are twice as likely to be stillborn, are just two examples of these systemic health inequalities within maternity care.
Yet it remains unclear how these recommendations will really tackle these stark disparities. The report recommends that all major health bodies, including the Department of Health and Social Care, the General Medical Council, NHS trusts and the Nursing and Midwifery Council (NMC) “must treat racism discrimination and inequality as a critical maternity safety issue within a year, starting immediately”.
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These measures include an independent evaluation of anti-racism training currently being delivered by these bodies, as well as NHS trusts taking immediate action to better record their inequalities data.
However, several of these bodies have already signalled their commitment to addressing racism and bias, such as the NMC publishing new anti-racist principles last month. But whether reviews of anti-racist training will actually contribute to eliminating the maternal death and stillbirth rates disparity is unclear.
The lasting impact traumatic births can have on mothers and families, such as experiencing serious tears and other birth injuries, are also not directly addressed by the report’s recommendations.
The Birth Trauma Association has described Amos’ review as a “huge missed opportunity” and “disappointing for families”, given that the report did not once mention the impact of forceps, often the cause of birth injuries, nor post-traumatic stress disorder or the psychological impact of traumatic birth on women or their partners.
So, while the report does contain concrete recommendations, whether these will bring about measurable change remains to be seen.
Read the full story at The Guardian ↗
Lady Amos has completed a review of England's maternity and neonatal services, finding the system no longer fit for purpose. This echoes conclusions from earlier reports, including Donna Ockenden's investigation into Nottingham NHS trust. The Amos review proposes concrete measures: families dissatisfied with internal investigations would gain automatic access to independent reviews; maternity triage services would become formally designated safety-critical environments with binding national standards rather than guidance; and an independent maternity commissioner would oversee system redesign. The review documents systemic racial disparities: black mothers experience nearly three times the maternal mortality of white mothers, and black babies face twice the stillbirth rate. It calls for major health bodies to treat racism and inequality as critical safety issues within a year, including independent evaluation of anti-racism training and improved data recording by NHS trusts. Some observers note the review does not directly address birth trauma, forceps injuries, or post-traumatic stress in families, and note that earlier commitments to anti-racism measures by bodies like the Nursing and Midwifery Council have not yet demonstrably reduced disparities.
Read the full story at The Guardian ↗
The findings of Lady Amos’ review into maternity and neonatal services across England, which state the system is ultimately no longer fit for purpose, are unsurprising. The systemic failures and inadequacies of these services have been uncovered in several reports already, including Donna Ockenden’s review of the “toxic” Nottingham NHS trust published last week.
But what this report does offer are a set of recommendations for the government to implement. Amos states that if they were to be delivered in full then “the overall safety and quality of maternity and neonatal care in England will be materially and sustainably improved”. But how far do these recommendations go, and what will it take for them to be implemented?
A recurring theme across multiple maternity investigations has been the experience of bereaved and traumatised families being left in the dark, often having to fight for years to uncover the truth about what went wrong in their maternity and neonatal care. Many reviews have identified a “cover-up culture” within NHS trusts, where failures were minimised or concealed, leaving families without answers and undermining accountability.
One of the clearest examples is the case of Sarah and Jack Hawkins, whose daughter Harriet was stillborn in 2016. Nottingham university hospitals NHS trust initially told the parents Harriet’s death had been unavoidable. It was only after the couple fought for an independent external review that it was revealed Harriet’s death was due to failures at the trust.
One of the key recommendations of the Amos review seeks to address this issue directly. It proposes that, once an NHS trust has completed all its internal investigations, families who remain dissatisfied with the findings should have an automatic right to request the trust commissions an independent investigation into the case.
If implemented, this recommendation would represent a significant step towards greater transparency and accountability for families seeking answers. In Harriet’s case, had such a mechanism already existed, her parents would not have had to battle so hard to obtain an independent review and establish the truth about what happened to their daughter.
The report also calls for binding national standards, rather than just guidance, which is now used in some instances for aspects of maternity care. Failures within maternity triage, which essentially serves as A&E for pregnant women, were described as “deeply concerning” by the report. They have been severely understaffed and lacking physical space in order to adequately address the needs of pregnant women who may present with serious symptoms and conditions.
Currently, there’s national guidance that sets out what minimum staffing and space levels at these triage services should be. But the report goes further by calling for maternity triage to be formally designated as a safety-critical clinical environment with binding national standards.
The report also calls for a maternity commissioner, who will be instrumental in “providing the leadership and oversight needed to drive accountability and implementation of a redesigned maternity and neonatal system”.
In May, the Labour MP Michelle Welsh was appointed the government’s first maternity adviser. However, the implementation of a maternity commissioner, wholly independent from the government, will be a more concrete step to ensuring transparency and accountability across the country’s maternity services.
The report also has its limitations. The review does not shy away from identifying the systemic “racism, discrimination and structural inequalities embedded throughout the maternity and neonatal system across England”. That black mothers are almost three times more likely to die in childbirth than their white counterparts, while black babies are twice as likely to be stillborn, are just two examples of these systemic health inequalities within maternity care.
Yet it remains unclear how these recommendations will really tackle these stark disparities. The report recommends that all major health bodies, including the Department of Health and Social Care, the General Medical Council, NHS trusts and the Nursing and Midwifery Council (NMC) “must treat racism discrimination and inequality as a critical maternity safety issue within a year, starting immediately”.
after newsletter promotion
These measures include an independent evaluation of anti-racism training currently being delivered by these bodies, as well as NHS trusts taking immediate action to better record their inequalities data.
However, several of these bodies have already signalled their commitment to addressing racism and bias, such as the NMC publishing new anti-racist principles last month. But whether reviews of anti-racist training will actually contribute to eliminating the maternal death and stillbirth rates disparity is unclear.
The lasting impact traumatic births can have on mothers and families, such as experiencing serious tears and other birth injuries, are also not directly addressed by the report’s recommendations.
The Birth Trauma Association has described Amos’ review as a “huge missed opportunity” and “disappointing for families”, given that the report did not once mention the impact of forceps, often the cause of birth injuries, nor post-traumatic stress disorder or the psychological impact of traumatic birth on women or their partners.
So, while the report does contain concrete recommendations, whether these will bring about measurable change remains to be seen.
Read the full story at The Guardian ↗
Lady Amos' review found England's maternity and neonatal system is no longer fit for purpose. Systemic failures in these services have been documented in several prior reports, including Donna Ockenden's review of Nottingham NHS trust. A recurring pattern across maternity investigations is families being left without answers due to cover-up culture within NHS trusts. Sarah and Jack Hawkins' daughter Harriet was stillborn in 2016; the trust initially said it was unavoidable, but independent review revealed failures. The Amos review recommends automatic right to independent investigation for families dissatisfied with internal trust findings. The review calls for binding national standards rather than guidance for maternity triage, which has been severely understaffed. An independent maternity commissioner is recommended to drive accountability and system redesign. Black mothers are almost three times more likely to die in childbirth than white mothers. Black babies are twice as likely to be stillborn compared to white babies. The review remains unclear on how its recommendations will tackle stark racial disparities in outcomes. Bodies like the NMC have already signalled commitment to anti-racism, but whether training reviews will eliminate maternal health disparities is unclear. The Birth Trauma Association described the review as a huge missed opportunity for not addressing forceps injuries, PTSD, or psychological impact on families. Whether the report's recommendations will bring measurable change remains to be seen.
Read the full story at The Guardian ↗
- Lady Amos' review concluded England's maternity and neonatal system is unfit for purpose, building on findings from multiple prior investigations including Donna Ockenden's Nottingham NHS trust report.
- Key recommendations include automatic right to independent investigation for dissatisfied families, binding national standards for maternity triage, and an independent maternity commissioner.
- The review identifies systemic racism and inequality—black mothers are three times more likely to die in childbirth than white mothers—but recommendations for addressing this through anti-racism training reviews remain untested.
- Birth Trauma Association criticised the review for not addressing forceps-related injuries, PTSD, or psychological impact of traumatic births on families.