Amos report: recommendations do not go far enough

In June 2024, the former Health Secretary, Wes Streeting announced a long overdue national review into maternity services, the National Maternity and Neonatal Investigation, appointing Baroness Amos as chair. This step was clear confirmation that maternity services nationwide are in crisis. And that crisis is deep. There has been a string of maternity scandals afflicting NHS Trusts in East Kent, Morecambe Bay, Shrewsbury and Telford, Leeds, Sussex, Kettering and Nottingham.

Last week’s publication of senior midwife, Donna Ockenden’s review into maternity services under the Nottingham University NHS Trust revealed widespread failings resulting in avoidable harm and death to more than 500 mothers and babies spanning over 12 years, with clear opportunities to take action to improve patient safety and avoid further avoidable harm and death having been missed. Concerningly, her much anticipated independent review into maternity services at Leeds Teaching Hospitals NHS Trust could reveal another large-scale scandal, with more than 250 families reporting harm caused to their babies over a period of some 15 years.

And today, amidst maternity scandal after maternity scandal, Baroness Amos’ review has finally been published, concluding:

“The maternity and neonatal system in England is no longer fit to consistently deliver high-quality, compassionate care to every woman and family, and requires urgent reform to put safety at its centre, embed a focus on listening to women and ensure anti-racist practice at every level.”

Unsurprisingly, she found maternity services were characterised by poor care and a failure to listen to women, with racism and discrimination “embedded throughout the maternity and neonatal system.”

Having met with over 400 families and received evidence from over 8000 people, Baroness Amos has made 8 recommendations, including:

• The creation of a new maternity commissioner who will be granted statutory powers and be responsible for overseeing a new national plan for services to tackle widespread variation in care. They will be accountable to Parliament, not to the government of the day and will have “a relentless focus on improving maternity and neonatal care”.  Baroness Amos maintains this commission will be an independent voice with oversight of recommendations, charged with setting standards, driving change and reporting to both families and Parliament, with reporting to Parliament taking place annually and to the Health and Social Care Select Committee twice yearly. It is anticipated that the Commissioner will ensure women’s voices are heard at the heart of Parliament. The report highlights “medical misogyny” resulting in a culture of women’s voices being consistently ignored and of women not being treated with kindness and compassion.
• NHS rotas must ensure obstetric consultants and anaesthetists are on duty around the clock on maternity wards to facilitate “timely critical senior decision-making and intervention 24 hours a day, seven days a week”. Baroness Amos found that hospitals were failing to provide night and weekend senior doctor cover, increasing the risk of harm.
• An overhaul of triage systems “where the early warning signs of problems can, and should be spotted” to save lives and reduce harm, with midwives dedicated to answering calls, providing timely advice and offering face to face appointments to women who remain concerned. Current triage services were deemed “the A&E service for maternity”, risking early warning signs of problems being missed.
• Racism, discrimination and inequality are to be treated as a “critical maternity safety issue”.
• Families should have the right to seek a fresh, independent investigation when things go wrong and they are not happy with the Trust’s own investigation.

Throughout the report, there are examples of “medical misogyny” and reference to “an embedded culture in which women’s voices are ignored”, the consistent theme being one of women and families not being listened to, which is of no real surprise, given this report comes in the wake of a series of maternity scandals in which reports of these issues have cropped up time and time again. Also noted is the fact that maternity care has not kept up with emerging complexities in labour and childbirth, with more mothers presenting with underlying health conditions, obesity and also that more women are having children later in life than previously, flagging the urgent need for better education and training.

Ministers are to publish a “comprehensive national action plan” in December to deliver long-term reform.

Now surely has to be the time to act decisively to tackle this crisis and improve standards of patient care and safety in maternity services. After the Francis report into the widespread failings at the Mid Staffordshire NHS Foundation Trust back in 2013, many NHS trusts promised to prioritise patient safety, embrace the values of transparency and accountability and learn from their mistakes, to ensure they were never again repeated. But Donna Ockendon’s review into Nottingham and now Baroness Amos’ national review worryingly reveal a deep-rooted and systemic problem – that there is an institutional reluctance at a senior level to learn from serious failures, to actively listen to concerns raised by both family and staff and also, to implement recommendations made by external reviewers and regulators (in the case of Nottingham, both an external review in 2016 and a CQC investigation in 2020 downgrading the Trust’s maternity services to “inadequate” contained recommendations).

Put simply, this means that vital and life-saving learning opportunities are missed. We learn through our mistakes. It is why black boxes are retrieved from aircraft that crash – to determine why the crash happened and to stop it from happening again, industry wide, crucially to save lives! But within the context of NHS maternity services, where substandard care can result in avoidable injury or death, the culture appears to be rotten. And this rotten culture, compounded by inadequate staffing, training and supervision, a culture of bullying and an undercurrent of racism and discrimination, can only lead to a devastating but inevitable downward spiral into ever poorer patient care and safety. As existing staff feel unsupported, burned-out and devoid of the resources and necessary training to deliver both competent and compassionate care, they may become desensitised to devastating events with uncompassionate and substandard care becoming the norm, especially if they have reported concerns to management, only for them to be dismissed. Some may leave the profession, or decide to practice overseas where the pressures are less, worsening the conditions for the reduced numbers left behind, and deterring new talent from entering the sector. It is hard to see how, from this dire position, any meaningful positive change can be effected and standards improved.

So many families have needlessly suffered the utter devastation and heartbreak of avoidable loss of or harm to mothers and babies. To add insult to injury, their legitimate and genuine concerns have been dismissed. And then, when they have had the courage to fight for answers, often motivated by the utterly honourable desire to ensure no other family should endure the suffering they have experienced, to learn that that harm or loss was basically in vain, must be unfathomably painful and distressing.

Whilst the recommendations must be welcomed, regrettably Baroness Amos’ report and recommendations do not go far or fast enough to address the deep rooted cultural issues at the heart of maternity services. We are close to, if not already at the point of this being a national emergency, with Donna Ockenden last week calling for urgent action, yet the government’s “comprehensive national action plan” will not be published until December, some six months away. Donna Ockenden has also today expressed concerns that the scale of the task at hand is too much for just one person. Many families are understandably disappointed that Baroness Amos’ recommendations do not include the public inquiry they say is now so desperately needed.

The key thread running through all of the maternity scandals to date is that families have never felt listened to and that their concerns have been dismissed and swept under the carpet. Yet, there is still a stunning lack of accountability for the unmeasurable suffering and pain they have experienced. Several members of the senior management team at the Nottingham University NHS Trust refused to speak with Donna Ockenden during her review into maternity services at the Trust. A public inquiry would compel those responsible to give evidence and allow more scrutiny, rather than evidence being gathered behind closed doors and only from those who are willing to cooperate. It would thoroughly lay bare the issues, which is what is needed if sustained and effective change is to be implemented. Indeed, if senior figures continue to refuse to contribute to maternity reviews, it is impossible to gain a full understanding as to why they failed to listen to affected families, to the concerns of staff and to act on recommendations made by external reviewers and regulators over the years, resulting in avoidable harm and death to mothers and babies.

It is the “why” here that is the key to addressing what is a deep rooted and cultural problem and to ensure the right people inhabit these senior positions; senior people who are passionate about and have the necessary skills and experience to drive positive change whilst ensuring that families’ and staff concerns are properly listened to and acted upon, that standards of patient safety and care are finally improved and ultimately that incidences of avoidable harm and death are prevented.

This blog was co-authored by Claudia Hillemand, Head of Child Brain Injury, and Caroline Klage, Head of the Brain Injury Division.