The chair of the Government’s independent investigation into maternity and neonatal services has said nothing could have prepared her for “the scale of unacceptable care that women and families have received, and continue to receive”. Nor “the tragic consequences for their babies, and the impact on their mental, physical and emotional wellbeing.” Delivering her first set of “reflections” since taking on the role, Baroness Amos said what she had found so far had been “much worse” than she had anticipated.
Following the announcement of the investigation in June by the Health Secretary, Wes Streeting, these are a first glimpse of what the Labour peer Valerie Amos has discovered. But there is little insight. “I have not included early findings or recommendations because I need to gather further evidence to inform my thinking,” Amos writes today (9 December). The report is branded, “Reflections and Initial Impressions”. Amos relays a long list of themes, familiar to anyone who has taken an interest in maternity care over the last decade. Issues that have been “consistently” raised include: women not being listened to or being given the right information to make informed choices; a lack of empathy; discrimination against women of colour, working-class women and others; the failure of regulatory bodies to protect vulnerable women and families; the perception that health professionals and organisations are “marking their own homework”; and a lack of compassionate care when a baby dies.
Amos is also concerned about the challenges faced by staff who are delivering maternity and neonatal services. Some have told her they have had “rotten fruit thrown at them and… faced death threats after negative publicity and social media posts about the standard of maternity care in their unit.” But the effect of press coverage of poor maternity standards could also be positive: staff said adverse media attention had also acted “as a catalyst for improvements in women’s experience of pregnancy and labour.”
These brief “reflections” were not what had been intended. The plan had been for the investigation to “look in detail at up to 10 maternity units that are giving us greatest cause for concern” and report directly to Streeting “by Christmas”. Neither has happened. Ten units became 14, and then 12 – Leeds Teaching Hospitals NHS Trust and Shrewsbury and Telford Hospital NHS Trust were removed in October. (Leeds families were granted their own separate inquiry, while West Mercia Police expressed concern about how their ongoing criminal investigation into Shrewsbury might clash with a separate review.) The trusts chosen weren’t necessarily those providing “greatest cause for concern” either – but rather picked to ensure there was, Amos confirms, “sufficient variety, not just geographically but also in terms of demographics, the mix of cases and the different types of Trust.” Poor outcomes and data were taken into account, but these weren’t the sole factors.
The task has been far bigger than anticipated, pushing back the timeline for any interim findings to February 2026. Only seven of the 12 trusts being rapidly reviewed have been visited so far, with the remainder to take place later in December and in January 2026. Upon being appointed to the role in August, Amos quickly recognised she would need more time to do a credible job. The investigation team are also mindful of how upsetting it may be to bereaved and harmed families to read detailed findings in the run-up to Christmas – a time of year when they are acutely reminded of their children who should be here to celebrate.
In her work so far, Baroness Amos has identified a poor standard of basic care. Women and their partners are being left in unclean facilities, not receiving meals. “Women not being helped to use the bathroom, and catheters not being checked or emptied,” are also noted by Amos. All of these, and far more besides, were identified by the New Statesman and Channel 4 News in a detailed investigation into maternity services provided by Oxford University Hospitals NHS Foundation Trust (OUH). At the time, we wrote that “the details of our investigation go far beyond what the rapid review team can hope to uncover in 48 hours”, and this has proved so. Today’s report makes clear that none of the local investigations Amos is undertaking will “consist of a formal evaluation or assessment of a Trust’s performance or the performance of individual staff members”. The purpose of visits to the 12 Trusts is “to identify systemic, national issues in maternity and neonatal care and make recommendations to address those.”
For the 730 families – and growing – who have shared their experience of poor care in Oxford this is not enough. “This statement suggests the investigation will describe what went wrong without saying who was responsible,” Rebecca Matthews and Kim Thomas said on behalf of the Families Failed by OUH campaign. “We deserve more than that – we deserve accountability and justice.” The campaign is “deeply concerned” at the appearance that trusts will be investigated, “without any formal assessment of whether they’re safe.” Hundreds of families say they are not, the pair added. Families, they explained, wanted “accountability for the Boards, executives, and clinical leaders whose governance failures allowed harm to continue for years,” as well as the proper investigation of individual cases.
The Health Secretary’s June investigation announcement also cited the intention for it to be “co-produced” with families. Yet, alongside an acknowledgment that families she has spoken with hold very different views on the best way forward, Amos concedes that this approach has not happened. “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 we have established,” she writes. Given families had been told this would happen, it is unsurprising that some have been left disappointed by the change in direction. But families have been – and will continue to be – asked for their views and input throughout. Amos says she is “hopeful” the investigation “will lead to systemic reform which will help families to receive justice.”
Wes Streeting said Baroness Amos’s update “demonstrates that too many families have been let down, with devastating consequences”. He acknowledged that NHS staff are “dedicated professionals who want the best for mothers and babies… but the systemic failures causing preventable tragedies cannot be ignored.” The Health Secretary confirmed that while Amos continued her work, a National Maternity and Neonatal Taskforce was being set up, which will be ready to implement her final recommendations as soon as they are ready. Some families told the New Statesman in November they were disappointed at proposals to have just three out of 15 places on the taskforce reserved for family representatives. However, I understand the make-up of the taskforce is still being actively considered, with the Health Secretary determined to get it right.
Baroness Amos will begin a new call for evidence in January 2026; families will have eight weeks to respond. She will also conduct interviews with representatives from a range of national organisations, including the Care Quality Commission (CQC), the Nursing and Midwifery Council (NMC), the Royal College of Midwives (RCM), and the Royal College of Obstetricians and Gynaecologists (RCOG). More detailed, initial findings will be published in February 2026, with Amos’s final report and recommendations due in spring. For many these cannot come soon enough. “I do not understand why change has been so slow,” Amos notes, adding that it is both necessary and urgent. “The NHS has recorded a staggering 748 recommendations relating to maternity and neonatal care”, she says, most coming in the last decade. We can only hope that Amos’s recommendations prove to be the last. And that this time, actions will follow.
[Further reading: What baby books taught me about the British state]
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