Baroness Amos’ Final Maternity Investigation Report: Key Findings and the Future of NHS Maternity Care

June 30th marks the publication of the final report and recommendations of the Independent National Maternity and Neonatal Investigation by Baroness Donna Amos.

The report ordered by the then Health Secretary, Wes Streeting concluded that women and babies throughout England were being failed "on a scale that shames our society.” The exiting system is not set up to deliver safe, high quality, consistent care

What the investigation comprised

It conducted reviews of maternity and neonatal services in the 12 trusts to identify systemic issues affecting services across England.

The investigation spoke to women, families and staff working at different services at different levels to create an accurate account. The picture was one of harm and bereavement suffered by families, and stress and burnout by staff.

Maternity investigator Donna Ockenden , who led recent investigations into failures at Nottingham and who will also chair the reviews in maternity services in Leeds and Sussex as commented that she has not learnt anything new.

This paints a bleak picture, but one that can be improved upon. It has identified barriers to delivering change and set out eight recommendations aimed at long-term systemic and cultural transformation fit for the modern era.

The findings:

1. Women were not being listened to, and excluded from decision-making

2. Staffing was inappropriate for demand and unable to meet needs and provide continuity of care

3. Demand and capacity were mismatched, with women with increasingly complex care needs, placing pressure on capacity, causing delay, overcrowding and inappropriate decisions based on available space rather than clinical need

4. Leadership and governance skills; there is a knowledge and capability gap, with uncertainty of who is in charge, preventing the right changes being put in place

5. Responses when things go wrong, not apologising, and instead, becoming defensive

6. Inequalities of experience, due to ethnicity, socio-economic status, language, disability, and gender

7. Estates in some units were simply not fit for purpose, with a lack of privacy for sensitive conversations and care delivered in cramped conditions

8. IT systems, lack of communication between systems that did not ‘talk to each other’ and share vital information. Inability to see the full picture consistently across platforms

Staff voiced concerns that delivering the care that people deserved could not be achieved where they were understaffed, and whilst operating in a blame culture, fuelled by the media.

Donna Amos has commented "we need national standards to frame maternity and neonatal care against which we can then test how trusts are doing, how care is being delivered.”

A tangible difference, what will change?

James Murray, speaking on Radio Five Live identified, an urgent need for change with a task force in place to establish the action plan by the end of 2026. It was levelled at him that there have been reviews, accepted and shelved in the past.

The next steps will include;

1. The appointment of a new Neonatal Commissioner, hailed as an important step in driving accountability. This person will have the power to hold the system to account in relation to the action plan. This voice of women should be heard at the heart of government. The commissioner, once in place will enforce the action plan and deliver.

2. Expanding Martha’ s Law to all maternity services to allow women to ask for an urgent second opinion.

3. Reform of the Care Quality Commission (CQC) following huge failings by regulators to perform their roles. This against a background of not putting women and patients first. Ultimately, they need to be in a better position to do that work.

4. An overhaul of maternity triage services to employ dedicated midwives to answer calls, provide timely advice, and offer face-to-face appointments where women remain concerned.

A more detailed view of the recommendations and the reports for each trust can be found here.

It's hoped that it will lead to a significant increase in the improvement in the experience of women and families and ability of staff to provide safe care.

Challenges remain, and whether this report will succeed where others appear to have been shelved and not implemented remains to be seen. It will need investment in the recommendations and the ageing infrastructure. We are a growing population and this places growing pressure on staff and infrastructure. Hopefully it will lead to a voice for women, safety netting , transparency and improvement across the board. Let’s hope the learning will be put into practice and the momentum for change continues. There is a huge appetite for this from the families that I represent.

How Forbes Solicitors Can Help You

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