On 30 June 2026, the final report of the Independent National Maternity and Neonatal Investigation was published by Baroness Amos.

The report found that England’s maternity system is fraught with poor care, avoidable harm, systemic cultural issues, and is failing women and babies. The report identifies eight core systemic areas of concern:

• Families are routinely not listened to and have their concerns dismissed throughout the birthing process. Clinical decisions are often made without their input or consent.

• Systemic racism and discrimination affect patient safety and clinical outcomes. Harmful racial stereotypes, reports of women and families having their concerns dismissed because of their ethnicity, and clear disparities in treatment have been found to contribute to adverse treatment experienced by women and families in maternity and neonatal care.

• Severe staffing shortages and workplace pressures.

• Capacity concerns as demand and number of clinically complex pregnancies increases.

• Defensive responses to harm and lack of accountability, openness and transparency when clinical errors occur. Apologies are often delayed or felt to be meaningless.

• Disconnected leadership: lack of governance between wards and at executive board level, leading to a severe deficit in clinical oversight.

• Inadequate buildings that are often outdated, unfit for care and fail to provide privacy to patients.

• Lack of cohesive IT systems between clinical settings leading to communication gaps and patient safety risk as data is not available or able to be transferred across clinical settings.

Recommendations highlighted in the report

The report sets out eight recommendations to overhaul the maternity and neonatal system:

1.    The creation of a statutory Maternity and Neonatal Commissioner to manage change

2.    For the system to "take action to listen to the voices of women, birthing people and families"

3.    To improve transparency and accountability of investigations, including providing an explanation for families when death or harm occurs.  

4.    To create a Modern Service Framework to set national standards for improved services.

5.    To address racism and discrimination as a critical safety issue.

6.    For the Modern Service Framework to include a "streamlined, national oversight and leadership model"

7.    To improve culture and teamwork throughout the organisation, including at board level, on wards and in the government department

8.    To improve estates and digital systems to ensure that are fit for modern maternity and neonatal care.

It is our view that while Baroness Amos’ report highlights pertinent issues facing neonatal and maternity care in England, it does not go far enough. Her report does not add new insight into ongoing issues entrenched in neonatal and maternity care, and fails to address other areas of concern, which we discuss below.

Suppression of ‘Normal Birth Ideology’

The Terms of Reference asked the report to investigate the extent to which a ‘normal birth ideology’ is promoted in maternity services. This concept is defined as a physiological birth without intervention such as pain relief, forceps, induction and caesarean section.

The report did not find that a normal birth ideology existed within maternity services. There was an acknowledgement that there were failures to recognise problems and escalate them appropriately, resulting in harm, and that women’s preferences and concerns were not always recognised.

Notably, Dr Bill Kirkup CBE, who chaired independent investigations into Morecombe Bay Maternity and East Kent Maternity Services, resigned from his role as an Expert Advisor for the National Maternity and Neonatal Investigation on 22 June 2026 due to the failure to include findings of the normal birth ideology in maternity care in England in the report.

Dr Bill Kirkup has said that "this is a patient safety danger and I think it should be called out as such." He has been a longstanding critic of the normal birth ideology and in his inquiry into Morecombe Bay and East Kent maternity services found that midwives were pursuing normal birth at any cost.

Reluctance to perform caesarean sections

In our experience as clinical negligence lawyers, we frequently deal with a high number of birth injury and fatality cases caused by a failure to deliver sooner. It is often the case that earlier indications for delivery were missed or ignored, creating a situation where emergency delivery is necessitated.

As a result, this increases the pressure on maternity services as immediate access to a delivery theatre, anaesthetist, obstetrician and relevant midwifery team is required, and often there is not the availability of staff and resources at that moment to meet this demand. Therefore, the risk to mother and baby is increased and frequently results in avoidable harm, namely birth injury and fatality. It is our experience that there is a reluctance to perform caesarean sections or other methods of assisted delivery until there is a situation where emergency delivery is required.

Maternity triage process in urgent need of review

The report acknowledges that the triage process is in urgent need of review as early warning signs and issues that should be identified prior to labour are being neglected and the concerns of women and families are often dismissed and ignored. The report states that if triage services are improved, then “lives will be saved and harm will be reduced”.

There is due to be a publication of the first National Maternity Triage Specification from NHS England of what constitutes good maternity triage services. It is our view that this must incorporate early warning signs and indications for earlier delivery, so that intervention can be considered at a time when it is safe to do so and can be arranged so the necessary resources are available.

Lack of input from senior staff

Furthermore, the Report has rejected the presence of the normal birth ideology based on an incomplete picture of clinical practice at the Trusts investigated. This is because the Report does not include input of senior staff at many Trusts involved in the investigation or from regulators such as the Care Quality Commission (CQC) and the General Medical Council (GMC).

Many families have reported feeling let down by the piecemeal approach to the investigation that omits important contributors to neonatal and maternity care. There have been calls for a Statutory Public Inquiry, which Baroness Amos has rejected. This has sparked criticism from many bereaved families and groups such as the Maternity Safety Alliance, who argue that a statutory inquiry with legal powers to compel evidence is the only way to get full transparency and the complete truth.

It is our experience that there is a reluctance to perform caesarean sections or other methods of assisted delivery until there is a situation where emergency delivery is required and that the Report was wrong to discard the promotion of the normal birth ideology and the dangers this poses to mother and baby.

Litigation and lack of accountability

The Report identifies that there is a lack of accountability, transparency and a defensive approach to harm caused. Apologies are often delayed, reluctantly given or felt by bereaved families to be meaningless.

The Investigation examined the role of coronial review and inquests, in particular into the investigation of stillbirths. At present, coronial review is only available when a baby has showed signs of life from birth and therefore does not include stillbirths. Many families feel as though they are not afforded the same opportunity for accountability and for an explanation as to what happened as they are denied access to the inquest process, adding to a lack of transparency in the investigative process.

By excluding stillbirth cases, many families feel as though their loss is not taken seriously, and by distinguishing babies as showing signs of life after birth as having the right to an inquest, many families of stillborn babies feel that this creates the impression their baby is not important.

Incentivised to record baby deaths as stillbirths

Furthermore, a lack of transparency, accountability and a ‘cover-up’ of the truth was found in the Interim Report, which reported that the NHS was incentivised to record baby deaths as stillbirths to avoid coronial investigation. This shocking revelation highlights the need for greater accountability and transparency throughout the maternity and neonatal process, including where avoidable harm and death has occurred.

Although the report remained contested on this issue and the government response to the 2019 consultation on extending coronal jurisdiction to stillbirths is awaited, in our view, by incorporating stillbirth cases from 24 weeks gestation in the coronial review and inquest process, this would promote greater accountability, transparency and a more open approach to harm caused in neonatal and maternity care.

Inequity of the inquest process

The Report mentions the inequity of the inquest process that is weighted against families. For many bereaved families, the inquest process is a rare opportunity to have independent investigation into the death of their baby that is not conducted by the hospital Trust that caused the harm. It is also an opportunity to ask questions directly to the clinicians involved in the deceased’s care and receive an explanation, and sometimes an apology. However, there is no state funding available for families and most people are unable to pay the costs of legal representation privately.

Therefore, the only way to fund inquests is through bringing a clinical negligence claim, which may not always be an option as an inquest is an investigation into a death that was unnatural or where the cause is unknown, which may not necessarily be negligent in the eyes of the law. In this situation, many solicitors are unable to take on inquest work where there is unlikely to be a clinical negligence claim as the costs will not be recoverable.

Families attending inquests without legal representation

Unfortunately, this leads to many families attending inquests without legal representation, while in contrast, the Trust are entitled to legal representation through lawyers instructed by NHSR, despite this also being funded by public expense. The inequality of access to justice denies many bereaved families the opportunity for accountability, to ask questions and be given an explanation that is so important for traumatised and grieving parents.

While the Report mentions the possible inclusion of stillbirth cases and families’ experiences and the inequality in the inquest process, there are no suggestions for reform to create a fair process. Additionally, while there continues to be a lack of accountability, transparency, cover-ups and a defensive approach to harm caused, the inquest process will remain a pivotal method for families to receive an explanation, although the inequity of the process against families must be addressed.

Claims process access needs to be addressed

Furthermore, the Report criticises the compensation process as being difficult to navigate and exacerbating trauma. It recognises that the process can be long, the burden of proof is on the claimant, and the system is weighted against them with many families needing to find the right solicitor that can take on their case and access the right funding while the Trust is provided access to senior lawyers at public expense.

However, the Report fails to consider ways in which the inequity of the system against claimant families can be addressed. For example, if during an inquest the coroner finds failures from the Trust that have contributed to the deceased’s death, there is no obligation for the Trust to make an admission or even to consider these independent findings in the following clinical negligence claim.

As a result, it is often that case that following an inquest, the family has to go through the clinical negligence process of the claim right from the beginning. Not only does this incur unnecessary costs when there has been independent investigation, submissions and independent findings in the coroner’s court, but it is also distressing for the families who have to face a longer and retraumatising process.

It also compounds the idea that there is a defensiveness and lack of accountability of Trusts, given that independent findings could be highly critical of their care, and they do not have to admit to this or take it into account in the subsequent legal process. The unfairness of the process against families and lack of accountability would be addressed if Trusts were obliged to make an admission if the coroner finds that their care more than minimally contributed to death.

Alternative approaches need to be viable

Instead, the Report discusses alternative approaches to compensation, including a no-fault system. It is our view that this is not a viable option when the Report has found an institutional culture of defensive responsive to harm and lack of accountability. It is therefore imperative that we have an adversarial system, as it remains the only way for families impacted by negligent care and harm to have this care independently investigated.

It is disappointing that the suggestions made for reform of the adversarial process of a no-fault scheme, Early Notification System and the fixed costs scheme are all schemes to limit the process and costs of litigation on behalf of the claimant. Despite acknowledging the disparity that Defendant Trusts have access to senior lawyers at the public expense, there is no suggestion of reviewing or limiting their litigation costs, despite their reluctance to make an admission.

Maternity Commissioner role and need for public inquiry

Baroness Amos flagship proposal in the Report is the creation of the Maternity Commissioner Role. This is a new statutory role which will be accountable to Parliament to oversee safety, drive improvement and enforce accountability.

The key powers for the role include:

• Enforcing minimum standards: Leading the new Modern Service Framework to establish legally binding national safety standards, ending the regional "postcode lottery" of care quality.

• Direct parliamentary accountability: Co-chairing a National Maternity and Neonatal Taskforce alongside the Secretary of State to drive a comprehensive national action plan directly into the Cabinet.

• Holding hospital boards liable: Exercising the authority to intervene in failing NHS trust boards, transforming toxic workplace cultures, and penalising institutions that mask safety failures.

• Eliminating institutional biases: Ensuring that the voices of women and families, particularly those facing embedded racism and medical misogyny, are systematically heard, believed, and acted upon

Doubts that this role can drive the scale of change needed

On paper these proposals sound like the way forward in driving change but there are real concerns about the feasibility of this role being truly independent but also the ability to drive the scale of change needed.

Donna Ockenden distanced herself from this role stating that she “not convinced that one person can take on the system” given the vast scale of the crisis. The Maternity Safety Alliance also labelled the role as “fundamentally dangerous” arguing that the placing the burden of an entire system reform onto a single person is flawed and unachievable mechanism.

This Report like the many maternity reports over the past decade have identified systemic issues throughout England’s NHS maternity services. There is nothing new in this report and we cannot see how the creation of this maternity commissioner role will lead to the enactment of real structural change and accountability.

Statutory public inquiry into England’s NHS maternity services

We have seen many reports, inquests, negligence claims all focused on trusts and staff at the frontline. Yet we have not seen a single examination of the Government, national bodies like the GMC, NMC, national bodies like the Royal Colleges and their policies and agendas in maternity over the last decade to see what role they have played and what needs to change. All investigations to date have highlighted what the issues are and as this Report has shown the recommendations have then not been implemented.

A statutory public inquiry into England’s NHS maternity services is what is needed to truly expose the reality of maternity services to then allow for the necessary changes to be implemented. A statutory public injury would have the:

• Power to compel evidence: A statutory inquiry can legally force hospital executives, clinical staff, and regulators to testify under oath and hand over internal documents.

• Expose the truth: Families argue that independent reviews allow senior hospital figures to hide behind corporate apologies while the true extent of failures and cover-ups remains concealed.

• Investigate the Regulators: Campaigners note that bodies like the Care Quality Commission (CQC) and General Medical Council (GMC) have escaped deep scrutiny. A judge-led inquiry would legally investigate regulatory negligence.

• Address "preventable deaths": With roughly 800 babies dying avoidably every year in the UK, families argue that the "normalisation of preventable harm" requires a legal response, not just another policy paper.

Baroness Amos’s has explicitly stated that a statutory public inquiry is not needed right now because in her view the statutory inquiries take "such a long time" to yield results.

Missed opportunity

In conclusion, the findings of Baroness Amos’s report were distressing, but not surprising. The Report has missed an opportunity to provide new insight into Maternity and Neonatal Care in England and to identify key areas that are affecting the safety of mothers and babies.

Moreover, the Report has failed to include the input of regulatory bodies and senior staff, omitting vital insight into the delivery and management of maternity and neonatal care services. A public inquiry is needed to compel evidence to provide families with the full and transparent report that they deserve.

As it stands, clinical negligence claims remain vital in providing independent investigation and justice for those affected by substandard and avoidable harm.