Amos review finds NHS maternity services not fit for purpose

An independent review led by Baroness Valerie Amos has concluded that NHS maternity services in England are not fit to deliver consistently safe, high-quality care, prompting renewed calls from affected families for a full statutory public inquiry. The report, commissioned by the government and published today, identifies a series of systemic failings including women not being listened to, embedded racism and discrimination, fragmented care, and a lack of accountability when things go wrong.

Baroness Amos and her team gathered evidence from more than 10,500 people, personally meeting over 450 families and visiting 12 NHS trusts. The review makes eight key recommendations, including the creation of a new statutory maternity and neonatal commissioner to drive change, the introduction of consistent national standards for care, an overhaul of triage services, and greater transparency in investigations. It also calls for racism, discrimination and inequality to be treated as a maternity safety issue.

However, many families who have suffered trauma and loss due to maternity failings have expressed deep disappointment with the report. Campaigners argue it does not go far enough and ignores critical areas such as birth injuries and the so-called 'normal childbirth' ideology. Emily Barley, co-founder of the Maternity Safety Alliance, whose daughter Beatrice died during birth in 2022, said the recommendations are 'completely inadequate' and that families have been 'completely dismissed'. Rebecca Matthews, co-founder of Families Failed by OHE Maternity Services, described feeling 'betrayed' and said staff voices had been emphasised over families' experiences.

In response, Health Secretary James Murray told the House of Commons that the government will appoint the first ever maternity and neonatal commissioner, who will co-chair a national task force. He also announced the rollout of Martha's rule to allow women and families to demand a second opinion, new national standards for maternity triage to be published this week, and an expansion of the perinatal equity and anti-discrimination programme to every trust. An extra 41 million pounds has been allocated to upgrade maternity and neonatal facilities, alongside 1,000 new temporary roles for newly qualified midwives.

Murray acknowledged the 'devastatingly familiar' pattern of failings highlighted in previous reviews, including those at Morecambe Bay, Shrewsbury and Telford, East Kent, and the ongoing Ockendon reviews in Leeds and Sussex. He said the government will publish a national action plan by December to drive long-term change, and that he is not taking a public inquiry 'off the table'.

Baroness Amos defended her approach, saying she believes her recommendations, if implemented, will lead to faster change than a public inquiry. 'If the Secretary of State and the task force take on board all the recommendations that we have made and start now, the changes that we need in terms of cultures and systems within maternal and neonatal care will happen more quickly,' she said. She added that she 'absolutely understands why families are asking for one'.

The report highlights stark racial inequalities: black babies are more than twice as likely to be stillborn than white babies, and black women are almost three times more likely to die during pregnancy or shortly after birth. Examples of discrimination included a Muslim patient being asked 'why are you wearing this?' and a Jewish family being told 'Jewish people are sneaky'.

Despite the criticism, the government insists this must be a 'watershed moment' and that the cycle of recommendations gathering dust must be broken. Families remain sceptical, with many saying they have heard similar promises before and fear little will change.