As the dust settles on a slew of damning reports into maternity services, NHS Trusts are now compelled to address the concerns raised and put measures in place to radically reform services and improve safeguarding.
Baroness Valerie Amos’ Independent National Maternity and Neonatal Investigation reported back on 30 June 2026, having launched in August 2025. Its recommendations are wide-ranging and urgent.
Baroness Amos outlined a simple objective for policymakers and NHS leaders.
She said: “A maternity and neo-natal system that delivers consistently safe, equitable and compassionate care and gives all women, birthing people and babies the high-quality care they need at the time they need it.”
At present, the system falls worrying short of that standard.
Recommendations for reform of NHS Maternity and Neonatal services
In the 174-page report, Baroness Amos called for “urgent reform” to meet the evolving demands on maternity services. This includes, responding to the rising age of birthing people, increasing levels of clinical intervention as well as society’s attitudes to women, ethnic and other minorities, and vulnerable individuals.
She set out eight primary recommendations for improvement. Key amongst them is the appointment of a statutory national Maternity and Neonatal Commissioner to oversee system-wide change and provide accountability. This, she suggested, should be included in the Health Bill currently working its way through Parliament.
Baroness Amos went on to urge the Health Secretary to enforce the following recommendations:
- Systematically listen to the voices of women, birthing people and families.
- Improve how the system responds and learns when something goes wrong.
- Create a Modern Service Framework which sets out national standards to consistently achieve high-quality maternity and neonatal care.
- Tackle racism, discrimination and inequality.
- Improve system governance and accountability structures and regulatory oversight.
- Improve culture and teamworking and strengthen leadership at all levels of the system and across professions.
- Deliver estates and digital systems that are fit for modern maternity and neonatal care.
Moreover, she called on NHS Trusts to immediately review triage processes, provide guidance for instances in which women refused clinical care, and assess the opportunity for a less adversarial compensation system for adverse outcomes.
Baroness Amos highlighted the “significant and evolving safety, ethical and legal challenge[s]” of an increasing number of women declining recommended clinical interventions or choosing to birth outside the NHS system. She called for national guidance “to support respectful, rights based, clinically safe care, including clear guidance on consent, risk communication, escalation, documentation and professional responsibilities”.
Mounting risk for all stakeholders
Baroness Amos’ report came less than a week after the Ockenden Maternity Review published its equally uncomfortable findings on Nottingham University Hospitals NHS Trust.
The 401-page report found that 444 women and 76 babies were harmed or died in “potentially avoidable” circumstances.
In her letter to the Secretary of State at the start of her report, Donna Ockenden, a senior midwife, reflected on the eye-watering cost of legal compensation, which she pointed out is almost equal to the cost of delivering maternity services.
Maternity services rank highest of all NHS services for the cost of compensation claims. Of the NHS’s £60 billion clinical negligence provision, maternity services account for £37.5 billion, or 62%, which is four times more than the next highest. Baroness Amos’ report highlighted the worrying number of claims for cerebral palsy or brain damage, which was up by 63% (£599 million) in maternity services between 2016/17 and 2024/25 to £1.6 billon.
But the cost of these failures far exceeds the financial and legal risk. As Ockenden’s heartbreaking report reveals, the human cost is unfathomable, affecting thousands of families and vast numbers of traumatised NHS staff.
She said: “Maternity systems are under increasing pressure due to the growing acuity of expectant mothers’ clinical needs, but this cannot by itself account for these worrying outcomes.”
In a plea reminiscent of Amos’ objective for maternity care, Ockenden added: “Safe and equitable care must now be the only acceptable standard.”
Elsewhere, independent reviews are being undertaken at Leeds Teaching Hospitals NHS Trust and University Hospitals Sussex NHS Foundation Trust and the Thirlwall Inquiry is due to be published in November 2026.
Recognised need for training and professional development
The reports published to date reveal a maternity service in crisis. The details of avoidable harm being caused to mothers, babies and wider families are devastating. As are the stories from traumatised maternity staff who have felt powerless in the face of the mounting systemic issues detailed in these investigations.
The weight of evidence is now undeniably that maternity services are failing in many parts of the country, presenting unacceptable personal and legal risks. The importance of a greater and more consistent emphasis on training and professional development across the service has been highlighted in several reports.
Both Baroness Amos and Ockenden’s reports highlighted poor recordkeeping, missed safeguarding opportunities, inappropriate treatment of vulnerable people and a growing trend towards women withdrawing from formal care pathways.
How we can help
Bond Solon has a suite of training resources focused specifically on the needs of maternity services. The package of materials includes comprehensive CPD-accredited courses on recordkeeping, safeguarding, the Mental Capacity Act and birthing outside the system.
To find out more about our maternity services package or to enquire about booking onto one or more of the courses, please email info@bondsolon.com or call 020 7549 2549 to speak a member of our team.