Baroness Amos has published her Interim Report in the Independent Investigation into Maternity and Neonatal Services in England after she was asked by the government to review maternity and neonatal services in 12 NHS trusts and across the whole maternity system in England to drive improvements.
The investigation’s Interim Report sets out the background and changing context in which maternity and neonatal care is provided and examines six factors that could be contributing to the pressures on the system:
- capacity pressures
- culture and leadership
- racism and discrimination
- poor responses and lack of accountability when things go wrong
- the quality of estates
- workforce.
The report states that “of great concern…are the levels of racism and discrimination we have heard about, exhibited by staff towards women and families, between staff, and by women and families towards staff” and that “many families…whose babies were stillborn, had not received a full explanation of what happened from NHS investigations.”
Baroness Amos says the interim report:
“I realise that some of the experiences identified in this report may be concerning for women and families currently using maternity and neonatal services. If you have concerns regarding your own care, I would like to reassure you that whilst there are many instances of unacceptable levels of care, there is also good practice across the NHS.”
However, families affected continue to call for urgent action. James Titcombe OBE, a prominent maternity safety campaigner whose son Joshua died in 2008 following major failings by University Hospitals of Morecambe Bay Foundation Trust, told the HSJ, “Baroness Amos is right to take a national, whole-system approach. But we cannot allow this to become another cycle of diagnosis without delivery.”
The interim reports says that the national investigation will continue to consider evidence from families, staff and stakeholder organisations to gain insights into governance and organisational structures, training, regulation and funding pathways for the different elements of maternity and neonatal services. Further evidence panels will also be held focused on inequalities, system wide working and the relationship between trusts and families, and previous recommendations will be considered.
Baroness Amos has acknowledged the immense contribution that women and families, community organisations and staff have made to the investigation so far. She recognises that families who have engaged with the investigation have done so because they do not want the same to happen to others, and equally that staff are committed to improving services. It seems clear that everyone involved is striving to ensure safe care.
The investigation’s final report and single set recommendations will be published in spring 2026. These will be considered by the government’s National Maternity and Neonatal Taskforce, which will be responsible for designing and implementing an action plan to deliver improvements in care, reduce inequalities in service provision and help affected families to receive justice in England.
Given the factors that have been identified in Baroness Amos’s interim report there does seem to be an opportunity to look at ways to improve maternity and neonatal services now. The issues already identified will perhaps not be unfamiliar to many, but starting a journey of improvement will if nothing else begin to benefit families and staff while the investigation’s full report is awaited.
