Why Do Maternity Failures Keep Happening? The Amos Review Must Finally Break the Cycle

Baroness Amos, Head of the National Maternity and Neonatal Investigation (NMNI), spoke to Radio 5 Live on 9th December 2025, ahead of her initial reflections on the process. She acknowledged that there had been a ‘staggering’ number of recommendations in the last decade, but the failure to provide safe care continues.

Common themes have been established in the preceding investigations, dating back to the Frances enquiry in 2013. Although not maternity-centred, it looked at failings across all services at Mid-Staffordshire NHS Trust between 2005 and 2009 and led to key recommendations which have gone on to be repeated in maternity care. Recommendations were made for increased standards of care, sufficient levels of appropriately trained staff, patient-centred care and a culture of openness and candour within the NHS.

Subsequently, maternity care at  Morecambe Bay NHS Foundation Trust was reviewed in 2015. This investigation followed the unnecessary deaths of 3 mothers and 16 babies over 9 years, between 2004 and 2013.

Shrewsbury and Telford Hospitals NHS Trust was under the spotlight in 2016, concerns having been raised about 23 cases of stillbirth, neonatal death and maternal death and brain injury at the maternity services. This led to the independent review by Donna Ockenden FRSA, inviting families to come forward with concerns about care.  It looked at cases between 2000 and 2018 and concluded that 300 babies had died or been left brain-damaged due to inadequate care and at least 12 mothers had died unnecessarily during childbirth. Again, multiple issues were identified, but themes included -

1. Poor working relationships, poor leadership and teamwork, with a culture of “them and us” between midwives and obstetric staff

2. Failure to listen to patients

3. Failure to follow clinical guidelines

4. Failure to learn and improve

In Wales, maternity services at Cwm Taf Health Board were placed in special measures in April 2019 due to ongoing concerns about culture, leadership and safety systems.

East Kent NHS Trust was scrutinised in an investigation led by Dr Bill Kirkup into the care provided between 2009 and 2020. The same issues resurfaced, including -

1. Failures in leadership and teamwork, and a lack of support from senior colleagues

2. High-risk patients are being managed by junior, unsupported staff

3. Lack of candour, poor risk recognition and missed opportunities to intervene

4. A culture of victim blaming

5. Failure to listen to families

In May 2022, Donna Ockenden FRSA started a further review of cases into maternity care at Nottingham University Hospitals NHS Trust, which will conclude in summer 2026. The Care Quality Commission brought charges against his Trust, which pleaded guilty to six counts of failing to provide safe care and treatment to babies and their mothers. A corporate manslaughter investigation into maternity services was launched by Nottinghamshire Police  in June 2025.

The Times reports that nearly 750 recommendations have been made for reform. The recurring themes demonstrate a persistent lack of joined-up thinking between trusts.

What Difference Will This New Investigation by Baroness Amos Make?

Evidence from families will be gathered in January, with the interim report provided in February 2026. She will not elaborate on when in ‘spring’ the final report is likely to be ready. This reluctance may be borne from her statement that “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: and the impact on their mental health, physical and emotional wellbeing.”

Amos has conducted site visits and identified consistent issues in care, such as not being listened to, a lack of information from mothers to make informed decisions about their care and discrimination against women of colour, younger parents and the working class. Typically, these groups are less well able to advocate for themselves. She will look at what recommendations have been made and that are working.

There have been several investigations in the past, but these have been looked at in isolation with a focus on a particular trust.

The 14 trusts that will be reviewed as part of the independent national investigation into maternity and neonatal services are as follows -

• Barking, Havering and Redbridge University Hospitals NHS Trust

• Blackpool Teaching Hospitals NHS Foundation Trust

• Bradford Teaching Hospitals NHS Foundation Trust

• East Kent Hospitals NHS Trust

• Gloucestershire Hospitals NHS Foundation Trust

• Leeds Teaching Hospitals NHS Trust

• Oxford University Hospitals NHS Foundation Trust

• Sandwell and West Birmingham Hospitals NHS Trust

• The Shrewsbury and Telford Hospitals NHS Trust

• The Queen Elizabeth Hospitals, King’s Lynn NHS Foundation Trust

• University Hospitals of Leicester NHS Trust

• University Hospitals of Morecambe Bay NHS Foundation Trust

• University Hospitals Sussex NHS Foundation Trust

• Somerset NHS Foundation Trust

These trusts were chosen based on multiple criteria, including MBRRACE-UK perinatal mortality rates, trust type, geographical spread and the care of patients from Black and ethnic minority backgrounds. Lessons from Shrewsbury and Telford, East Kent and Morecambe Bay will be incorporated into this review. Hopefully, this should give an indication as to how far maternity services have come. For the first time, the aim is to bring previous findings together into one clear set of national recommendations.

Learning - and Acting - Must Finally Take Place

Experience must be shared, and recommendations implemented consistently. From my own work supporting women and families affected by catastrophic maternity failings, it is clear that these issues are neither isolated nor new. Where there is responsibility, there must be accountability and meaningful learning. The consequences of maternity failures are lifelong and profound. Families deserve better and they have waited far too long.