- Baroness Amos publishes initial maternity review report
- Performance of 12 trusts will not be evaluated
- Bereaved parents claim review “contributing to ongoing harm”
The “rapid national investigation” into maternity care failings launched by Wes Streeting will not formally evaluate the performance of the 12 trusts involved, it has emerged, as families criticised the government’s “light touch” approach.
Review lead Baroness Amos has today published the first of three reports into maternity and neonatal services in England, revealing her “reflections and initial impressions” – with full findings due in the spring.
The first report follows the health and social care secretary announcing the review of maternity service failings in June, when he pledged that “we must ensure real accountability when things go wrong”.
However, the local investigations of trusts included in the review will now not consist of a formal evaluation or assessment of an organisation’s performance or the performance of individual staff members with the review lead stating the focus is on identifying “systemic, national issues”.
The report said: “I want to make clear that, although we are conducting local investigations of specific trusts, the aim of the investigation is to identify systemic, national issues in maternity and neonatal care and make recommendations to address those.
“The local investigations will not, therefore, consist of a formal evaluation or assessment of a trust’s performance or the performance of individual staff members.”
This prompted an angry response from bereaved families who contributed to the review, who claimed that its “light touch” approach and a failure to call for a public inquiry was “contributing to ongoing harm” (see box below).
Amos highlights poor basic care and lack of empathy
The report does however give a scathing assessment of the state of the NHS’s maternity services both for the “unacceptable” care it gives to patients and the working conditions for staff, some of whom have faced death threats.
Baroness Amos said: “Nothing prepared me for the scale of unacceptable care that women and families have received, and continue to receive, the tragic consequences for their babies… With so many far-reaching reviews already completed, why are we in England still struggling to provide safe, reliable maternity and neonatal care everywhere in the country?”
The baroness added that despite the health service recording a “staggering” 748 recommendations relating to maternity and neonatal care, mostly since 2015, “I do not understand why change has been so slow”.
Other issues highlighted in the initial review include:
- Women not being listened to and concerns about their own bodies being disregarded;
- lack of empathy, care or apology both in clinical care or when things go wrong;
- failure of regulators to protect women and families, with concerns about organisations “marking their own homework”;
- failure to address poor behaviour and poor standards of basic care;
- and the impact of discrimination against women of colour, working-class women, and those with poor mental health.
It also outlines a plan to review the legal framework for coronial involvement in the investigation of stillbirths and says methodology and evidence gathered will not be restricted to 37 weeks’ gestation and onwards. However, this wording remains unchanged in the terms of reference.
The baroness also highlights the impact of negative publicity relating to poor maternity care on staff, adding that some had rotten fruit thrown at them and received death threats.
Increased reporting processes, issues with hospital estates, lack of interoperability of IT systems and the impact of different leadership styles on care delivery were also cited as pressures on maternity staff.
Review ‘contributing to ongoing harm’ – family
Thomas Hender, whose son Aubrey was stillborn at the former City Hospital in Birmingham in 2022, cited research by Sands and Tommy’s which highlighted that 800 babies’ lives in the UK might have been saved annually by better maternity care.
He told HSJ: “By not calling for a public inquiry, this is actively contributing to continued harm [like that cited by Sands]. This review is not an inquiry, is light touch, and it gives the impression that they have done something to address this, when actually they haven’t. They’ve touched part of the problem.
“And there is inquiry fatigue – despite all of these previous local investigations, we still don’t know what to do about the problem, and doing another thing that is still not enough, and doesn’t include regulators, royal colleges, or other bodies, actively contributes to ongoing harm.”
Meanwhile, Rhiannon Davies, who lost her daughter Kate in 2009 due to mistakes made by the Shrewsbury and Telford Hospital Trust, said she felt the baroness had grasped headline themes.
But she added: “I am surprised she [Amos] mentions the impact on staff right at the outset. The rotten fruit and death threats… are not representative of people like Kayleigh Griffiths, James Titcombe [whose daughter Pippa and son Joshua also died due to hospital failings] and I who have all campaigned with dignity.”
Baroness Amos also writes in her review that “some families would like to have been more closely involved in determining the direction of the investigation through a co-production model, rather than the engagement and consultative processes established”.
Mr Hender said this was a “complete misrepresentation”, adding: “That [co-production] is what was promised by the secretary of state, and that’s why families felt some positivity about it.
“Then someone got a letter saying that co-production would not be possible in the timescale. Given that now a rapid review is out of the window, it feels like that is now a choice rather than a constraint.”
Emily Barley, co-founder of the Maternity Safety Alliance which is calling for a statutory public inquiry on maternity, said the review was “superficial and completely inadequate” and that she did not understand why Mr Streeting was “allowing this farce to continue”.
Ms Barley, whose daughter Beatrice died during labour at Barnsley Hospital in 2022, added: “When Wes Streeting announced this ‘rapid investigation’ we were promised justice, accountability, change, and more. Instead of any of that, today in Baroness Amos’ ‘initial reflections’ we see staff feelings prioritised and minimisation of the avoidable harm taking place in NHS maternity services every day.
“And so we must be absolutely clear: we did not have a ‘poor outcome’ or a ‘poor experience’ as described in Amos’ report – our children were starved of oxygen and killed or suffered serious life-changing injuries.”
NHS England’s chief nursing officer Duncan Burton said: “Baroness Amos’ independent investigation is a crucial step in driving meaningful change in maternity and neonatal care and we welcome her reflections and initial impressions.
“Whilst we have dedicated teams working across the country to improve services, we must do more to ensure that every woman and baby receives the safe, compassionate care they deserve. We will continue to work with colleagues across the NHS to address the issues raised.
“I want to reassure women and families that staff are continuing to work hard to provide the best possible care and want to do everything they can to support them – we would encourage them talk to their midwives and maternity teams if they have any concerns.”
The Department of Health and Social Care was asked to comment.
Updated at 7.37am, 9 December, to add NHS England’s response.
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Independent Investigation into Maternity and Neonatal Services in England – Reflections and Initial Impressions
Source Date
December 2025
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