Amos review: England's maternity care 'no longer fit for purpose', government to appoint commissioner
A government-commissioned review led by Baroness Valerie Amos has concluded that maternity and neonatal care in England is 'no longer fit to consistently deliver high-quality, compassionate care', citing systemic racism, fragmented services, a failure to listen to women and a 'postcode lottery' in standards.
The 181-page report, published on 30 June 2026 after a nine-month investigation, heard from more than 450 families and visited 12 NHS trusts. Baroness Amos said she was 'shocked' by the 'fragmentation, inconsistency and overall system failure' she uncovered.
A system that fails to listen
The review found that 'women and birthing people not being listened to, heard or believed' had 'serious consequences for the safety and quality of care', leading to avoidable harm and trauma. Racism and discrimination were described as embedded throughout the system, with a recommendation that unequal outcomes be treated as a critical safety issue and escalated to board level when patterns emerge. The report also identified a 'cover-up culture' within some NHS trusts, leaving families to fight for years for answers.
I still find it shocking that women and babies have been harmed or have died, sometimes as a result of failings in the maternity and neonatal care provided. We are a wealthy country. It should not happen.
Recommendations for urgent reform
The review sets out a package of reforms: an automatic right for families to an independent investigation when they dispute internal NHS findings, binding national standards to replace current guidelines, a comprehensive overhaul of hospital rotas to ensure 24/7 consultant cover, and a redesigned triage service with dedicated midwives. Amos noted that caesarean section rates are rising year on year but trusts had done little to expand theatre capacity.
The commissioner and government response
Health Secretary James Murray accepted the central recommendation to create a national maternity and neonatal commissioner. The commissioner, widely expected to be Donna Ockenden, will co-chair a taskforce drawing up an action plan due in December 2026. The role is intended to hold hospitals to account and drive consistent improvement.
Nobody is clear about who is in charge of improving standards.
Calls for a public inquiry and internal dissent
Bereaved families and the Maternity Safety Alliance criticised the report as insufficiently independent and renewed demands for a statutory public inquiry, labelling the commissioner proposal 'fundamentally dangerous'. It also emerged that Dr Bill Kirkup, who led earlier inquiries into Morecambe Bay and East Kent, resigned as an expert adviser after disagreeing with Baroness Amos over the extent to which a 'normal birth ideology' had caused harm. Amos concluded that this ideology was not currently widespread in the services she visited.
The human toll
Cases such as that of Sarah and Jack Hawkins, whose daughter Harriet was stillborn in 2016 and who were initially told her death was unavoidable, illustrate the damage when families are not given honest answers. The review argues that an automatic right to an independent investigation would mean families no longer have to wage protracted battles to uncover the truth.
