Baroness Amos review finds NHS maternity services not fit for purpose
An independent review led by Baroness Amos has concluded that NHS maternity services in England are not fit to deliver consistently safe care, prompting calls for a public inquiry and recommendations for reform including a maternity commissioner.
Narrative Synthesis
Neutral news article compiled by integrating coverage details from all reporting stations.
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 and compassionate care. The report, published today, found repeated failings including women not being listened to, embedded racism and discrimination, and a fragmented system with inconsistent care. It makes eight key recommendations, including the creation of a statutory maternity and neonatal commissioner, new national standards for triage, and greater transparency in investigations.
The government has accepted the need for urgent reform. Health Secretary James Murray told the Commons that the government will appoint the first ever maternity and neonatal commissioner, a statutory role with responsibility for driving change across the NHS. He also announced new national triage standards to be published this week, and the rollout of Martha's Rule to allow families to demand a second opinion. A national action plan is due by the end of the year.
However, many families who have suffered harm or loss say the review does not go far enough. Bereaved parents and campaigners are calling for a full statutory public inquiry, arguing that previous reviews have led to little change. Emily Barley, whose daughter Beatrice died during birth in 2022, said the recommendations were "completely inadequate". Rebecca Matthews, co-founder of Families Failed by OHE Maternity Services, described feeling "betrayed" and said the report emphasised staff voices over families' experiences.
The review gathered evidence from more than 10,500 people, including 450 families and 9,000 staff across 12 NHS trusts. It found that racism and discrimination are a critical safety issue, with black babies more than twice as likely to be stillborn as white babies, and black women almost three times more likely to die during pregnancy or shortly after birth. The report also highlighted cases of stereotyping, such as a Muslim patient being asked "why are you wearing this?" and a Jewish family being told "Jewish people are sneaky".
Baroness Amos defended her decision not to call for a statutory public inquiry, saying that if the government and task force take on board her recommendations, change will happen more quickly. But critics, including some of the families she met, argue that the review ignored key issues such as the "normal childbirth ideology" and birth injuries. Dr Bill Kirkup, a former advisor to the review, resigned over disagreements about the conclusions on pressure to avoid medical intervention.
The report is the latest in a series of investigations into maternity failings, following reviews into Morecambe Bay, Shrewsbury and Telford, East Kent, and Nottingham. Ministers have promised that this time will be different, with a focus on accountability and cultural change. The health secretary said: "This has to be a watershed moment. We must break the cycle of recommendations sitting on a shelf gathering dust."
On screen
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Key Claims
Factual or political claims reported during this story's coverage, mapped by channel. Ordered by how many channels carried each claim.
| Claim | Channel 5 | BBC One | Channel 4 | ITV | Sky News |
|---|---|---|---|---|---|
| The government announced immediate measures, including appointing a maternity commissioner, new triage standards, and expanding an anti-discrimination program. | |||||
| The review found that NHS maternity services in England are not fit to consistently deliver safe and high-quality care. | · | ||||
| The review identified failings including women not being listened to, embedded racism and discrimination, and fragmented care. | · | ||||
| The review made eight recommendations, including the creation of a statutory maternity and neonatal commissioner. | · | ||||
| Baroness Amos stated she does not believe a statutory public inquiry is necessary. | · | · | |||
| The government will publish a national action plan in December. | · | · | · | · | |
| The NHS is piloting Martha's Rule in maternity services to allow families to ask for a second medical opinion. | · | · | · | · |
Channel Perspectives
Editorial focus, emphasis angles, and key quotes from each reporting news station.
Sky News focused heavily on the disappointment and anger of bereaved families, giving extensive airtime to campaigners who said the review did not go far enough. The channel also promoted its own data tool allowing viewers to compare local maternity services. The tone was critical of the review's adequacy.
- “I'm devastated by what Baroness Amos has come out with as her recommendations. They are completely inadequate. They will not make a difference.”
- “Feeling let down doesn't really encompass how I'm feeling. It's a sense of being betrayed and having your hope taken away from you.”
- “You want to believe that change will happen and you want to have faith in the people with power to be able to do that, but unfortunately it looks like this was a real missed opportunity.”
5 News framed the story as yet another report in a long line of failures, emphasising the repeated nature of the problem. The channel interviewed MP Michelle (national maternity advisor) who shared her own experience of not being listened to, and included a whistleblower midwife. The tone was urgent and focused on the need for action.
- “You just give up. You give up trying to improve the service because you go in and just hope that nothing drastic happens on your share.”
- “It is dangerous to put all of the responsibility in the lap of one person.”
- “I wasn't listened to. It did put me and my baby in danger. I begged to be taken into the hospital and they told me I was a first-time mother, I didn't know what I was talking about.”
BBC ONE West gave a balanced overview but highlighted the families' call for a public inquiry and the health secretary's response. The report included a warning about distressing content and used a correspondent to explain the findings. The tone was measured but acknowledged the severity of the failings.
- “Our daughter should be three years old in September and she's a box of ashes because the system failed.”
- “I do hope the fact that there has been so much focus on these issues means that women and families understand and know that they have rights.”
- “This has to be a watershed moment. We must break the cycle of recommendations sitting on a shelf gathering dust.”
ITV1 focused on the human stories of families who lost babies, such as Bryony Russo, and included an interview with a charity head. The channel also discussed Martha's Rule and the government's immediate steps. The tone was empathetic and critical of the system's slow progress.
- “Emmy was right there, she was right there to live, and they just never delivered her safely.”
- “I don't want another parent to go through what we've gone through and what we are currently living through.”
- “The taskforce really needs to go back to basics in a way and build what that looks like for the future.”
Channel 4 provided a detailed, investigative angle, including an interview with the health secretary where he was pressed on safety and accountability. The channel highlighted the families' fight for truth and the resignation of Dr Bill Kirkup. The tone was probing and critical of the government's response.
- “It just needs to go so much further. We really need to look into understanding why so many of the regulatory bodies have been failing again and again.”
- “A public inquiry is looking back to try and achieve that effectively. What Baroness Amos has delivered is a piece of work along with other reports we've had recently, which give us the building blocks to create positive change.”
- “I think basically that is what has happened too often. NHS trusts put themselves and their reputation before bereaved families.”
Bulletin Timeline
Chronological list of news reports tracked for this story.