England's maternity system unsafe and discriminatory, review finds as government appoints first commissioner
Baroness Amos's long-awaited investigation finds a system marked by poor care, racism, and a failure to listen, while bereaved families label a proposed national maternity commissioner 'fundamentally dangerous' and renew calls for a statutory public inquiry.
Widespread systemic failings
Baroness Valerie Amos's National Maternity and Neonatal Investigation, published on 30 June 2026, concludes that England's maternity system is not set up to deliver consistently safe care. The report, commissioned by then-Health Secretary Wes Streeting in June 2025, drew on evidence panels with 323 affected families and visits to 12 NHS trusts. Amos writes that "words cannot describe the pain, suffering and trauma I saw and heard time and time again," and states there is "absolutely no justification for the tragic cases of unsafe care and avoidable harm we continue to see." Among the findings were that women were not believed, listened to, or taken seriously, and that the system is plagued by racism and discrimination. Maternity triage services, described as the childbirth equivalent of A&E, require urgent overhaul.
A national commissioner – and immediate backlash
Responding to pressure, Health Secretary James Murray announced the recruitment of the UK's first commissioner for maternity and neonatal care. The role would pursue hospitals over persistent failures, drive improvements, and restore families' trust. The Maternity Safety Alliance, however, called the proposal "fundamentally dangerous." Co-founder Emily Barley, whose daughter Beatrice died due to failings at Barnsley hospital in 2022, told BBC Radio 4's Today programme that "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 said the plan "seems designed... to grab headlines, but not to make the change that we need" and that nothing in the report would have prevented her daughter's death. Lady Amos defended the commissioner, insisting "this is not about concentrating power in the hands of one person. It is about saying that you need an independent voice and advocate for women and families."
Kirkup resignation and normal birth dispute
A dispute over 'normal birth ideology' led Dr Bill Kirkup, who chaired inquiries into Morecambe Bay and East Kent maternity scandals, to resign as an expert adviser to the review. He reportedly sought a stronger condemnation of the patient safety consequences of the ideology than Amos was willing to accept. The review stated it "did not find that 'normal birth ideology' was currently widespread in the maternity services we visited in England." Campaigners say the investigation lacked true independence, noting that team members were drawn from NHS England and the Health Services Safety Investigations Body. The Maternity Safety Alliance added that the report failed to scrutinise regulators such as the General Medical Council and Nursing and Midwifery Council, and did not examine post-death care.
Local stories reveal human cost
Alongside the national report, several new local accounts emerged. At Morecambe Bay's Furness General Hospital, where 11 babies and one mother died between 2004 and 2013, an investigation found women were made to "feel like a burden on the service" and left "frightened and uncertain." Oxford University Hospitals apologised for failings that led to a stillbirth after a couple's concerns were "dismissed" by midwives. A Gloucester family whose baby died shortly before birth after they repeatedly raised fears about her size also heard an apology for not being listened to. In Bradford, a trust chief executive admitted women had not been "believed, listened to or taken seriously" despite recent CQC ratings of Outstanding for neonatal care and Good for maternity services.
Words cannot describe the pain, suffering and trauma I saw and heard time and time again when talking to women and families about their experiences of maternal and neo-natal care in England.
Concentrating all of the power and responsibility for turning around maternity services in the hands of one person is, in my view, just insane. It's not achievable. It seems designed to me to grab headlines, but not to make the change that we need.
This is not about concentrating power in the hands of one person. It is about saying that you need an independent voice and advocate for women and families.
