On 30 June 2026, Baroness Amos published the final report of the independent National Maternity and Neonatal Investigation. Its message is blunt: too many women are still not being “listened to, heard or believed”, and the system needs urgent change.
The review was substantial: the team spoke to over 450 families, received more than 10,500 responses to a public call for evidence, heard from over 9,000 staff, and reviewed services at 12 NHS trusts, with a separate report published for each.
The report identifies women and birthing people not being listened to as the system’s biggest failing, warning that this can lead to avoidable harm, trauma and a loss of trust in the NHS. It also found racism, discrimination and inequality embedded throughout, and services that have evolved “in an unplanned, reactive and piecemeal way” rather than being designed to be safe. Families described being brushed off when they raised concerns and being unable to give proper informed consent because no one explained what was happening.
The financial cost is stark: maternity claims account for 62% (£37.5bn) of the NHS’s total £60bn clinical negligence bill. As the report puts it, these “are not abstract figures – they represent real harm and trauma to families, that in many cases could and should have been prevented”.
The report makes eight recommendations. At their heart is a new statutory Maternity and Neonatal Commissioner, to be legislated for in the Health Bill “at the earliest possible opportunity” and appointed within six months of the law passing, who would redesign services through a new “Modern Service Framework” setting minimum safety standards. One change that can happen now is an overhaul of maternity triage, which the report says has effectively “become the Accident and Emergency service for pregnancy related concerns”.
A divided response
The proposal for a single commissioner has split opinion. Emily Barley, co-founder of the Maternity Safety Alliance, called it “fundamentally dangerous”, arguing that putting all the power to fix maternity services in one person’s hands was “just insane”; the Alliance, which wants a statutory public inquiry, said the report “failed to address core issues at the centre of maternity failings”. Dr Kim Thomas of the Birth Trauma Association called it a “huge missed opportunity”.
Strikingly, Donna Ockenden, the senior midwife tipped to take on the role – suggested she might not accept it, asking “can one person actually fix this system?” Dr Bill Kirkup, who investigated failings in Morecambe Bay and East Kent, resigned as a clinical adviser. Others were more positive: campaigner Rhiannon Davies welcomed the report for treating listening to women “as a patient safety issue rather than simply an issue of patient experience”.
Baroness Amos acknowledged calls for a statutory public inquiry but said she was not convinced one was needed, noting such inquiries “take a very, very long time”. The Department of Health and Social Care has promised “urgent steps”, with a national action plan due in December and £41m of investment to improve safety.
Potential civil claims
Families who have suffered harm as a result of poor maternity or neonatal care may be able to bring civil claims for damages. These claims can provide compensation for the harm experienced and help meet the costs of ongoing and future care and support. Our Head of Clinical Negligence, Ally Taft, would be happy to speak to anyone affected in confidence.
