Government promises to act after ‘shocking’ failings in maternity care in England

The government said it will move quickly to appoint a new maternity commissioner for England after a damning report found the system was not set up to deliver high quality or compassionate care.

A rapid review led by Baroness Valerie Amos called for urgent change in the way patients were treated, with too many women not being “listened to, heard or believed”.

But one of the report’s key recommendations – the creation of a maternity commissioner to oversee improvements – was strongly criticised by some families.

Emily Barler, whose daughter Beatrice died at Barnsley hospital in 2022, told the BBC the idea was “fundamentally dangerous” and placed too much power in the hands of one person.

Other groups representing families reacted with disappointment to the report, which was ordered by then health secretary Wes Streeting last summer.

The Birth Trauma Association described it as a “huge missed opportunity” with the views of staff given too much weight compared to the experiences of patients.

“It is devastating to see that so little of what women told Baroness Amos is reflected,” said Chief Executive Dr Kim Thomas.

She said injuries caused by forceps deliveries and the impact of post-traumatic stress on women and their partners were not mentioned.

Health Secretary James Murray said he was unable to confirm a timeline for the appointment of the maternity commissioner role, telling BBC Breakfast his team would “move as quickly as we can”.

But maternity investigator Donna Ockenden, who led a recent investigation into failings in Nottingham and was one of those tipped for the new role, suggested she may not accept the job if offered it.

“Maternity services have not improved in the last two years, and my concern now is, can one person actually fix this system?” she told Times Radio.

She said that she was grateful to Baroness Amos for pulling together evidence from across England but felt she had not learnt anything new after reading the report.

“I am disappointed that we’re seeing the same themes over and over again,” she said. “What we need to do is get on and fix the problem.”

Another safety expert, Dr Bill Kirkup, who investigated maternity services in Morecambe Bay and East Kent, resigned as one of Amos’s clinical advisers.

He is understood to have disagreed over her finding that a drive in some maternity units for normal (vaginal) birth, including denying women caesarean sections, was not prevalent nationally.

Baroness Amos was asked to write her report after a series of individual maternity scandals undermined the trust of many families in the NHS.

Her team heard from more than 450 families and visited 12 NHS hospitals in England to understand what change was needed.

The key failing identified was an unwillingness to listen to women and families, leading to poor outcomes. There was a lack of a consistent standard of care, with large variations across the health service.

The system was “fragmented, overly complex and too slow to learn and improve,” the report found.

In her recommendations, Baroness Amos called for an immediate overhaul of maternity triage services, which were described as “increasingly becoming the A&E service for maternity”.

As part of that, dedicated midwives should answer calls and provide timely advice, while women should be offered face-to-face appointments if they were still concerned. If those changes were made, the report said, “lives will be saved and harm reduced”.

Racism and discrimination must be treated as a critical safety issue, the inquiry found, requiring urgent intervention, including gathering data on unequal outcomes that can be escalated to board level when patterns emerge.

Speaking to BBC Radio 4’s Today programme, Baroness Amos said the system was “not fit for the now and it’s not fit for the future”.

“We need national standards to frame maternity and neonatal care against which we can then test how trusts are doing, how care is being delivered,” she added.

She acknowledged calls by some families for a statutory public inquiry that would compel senior figures at hospital trusts to give evidence, but she said she was not supportive of the idea.

“Statutory public inquiries take a very, very long time,” she said.

“From the work that I have done and from the conversations that I have had with families, I don’t at the moment see that there is a need for a statutory public inquiry, but that’s not a decision for me to take.”

The eight recommendations made in the report are:

Bereaved parent Rhiannon Davies, who campaigned for a review into maternity failings in Shrewsbury and Telford after the avoidable death of her daughter Kate in 2009, said she broadly welcomed the report’s findings.

“One area where I think the report is particularly strong is that it reframes listening to women as a patient safety issue rather than simply an issue of patient experience,” she said.

“The report also places considerable emphasis on maternity triage. Again, I think this has huge potential – but only if we get it right.”

Helen Gittos, whose baby daughter Harriet lived for a week after sustaining a brain injury under the care of the East Kent NHS Trust in 2014, said she had mixed feelings about the report.

Gittos, who is chair of the family expert reference group for the National Maternity and Neonatal Taskforce, thinks many of the recommendations will make a real difference if they are implemented “fearlessly in a way that tackles the core issues and does not water them down”.

But she was “dismayed” after reading the report’s depiction of East Kent, one of the selected trusts, which she felt was “overly positive”.

“If improvement in an individual trust cannot be sustained even with intensive support from national teams it indicates that the support they are giving is not working,” she added.

Meanwhile, the Maternity Safety Alliance (MSA), which represents families who are calling for a public inquiry, said the report “failed to address core issues at the centre of maternity failings”.

The MSA said the recommendation for a maternity commissioner in the format proposed by Baroness Amos would “not be meaningfully independent and will not be able to create real change.”

Emily Barley, the group’s co-founder, said the proposal was “designed to make headlines but not actually make the change we need”.

“Concentrating all of the power and responsibility for turning around maternity services in the hands of one person is, in my view, just insane,” she told the Today programme.

The Department of Health and Social Care said it would take “urgent steps” in response to the “landmark” investigation.

It pledged to publish a national action plan in December to overhaul services, alongside £41m investment to improve safety in maternity and neonatal care.