Amos report: Lessons beyond maternity services

There are investigations and inquiries going on up and down the country. We have recently written about the Muckamore Inquiry. However, we also thought we would put pen to paper on some key points from the independent investigation into maternity and neonatal services in England published last month.

The 174-page report was published having listened to over 450 families, reviewing 10,500 responses (following a call for evidence) and hearing from over 9.000 staff.

Baroness Valerie Amos found that the system is currently too slow to learn and improve and that there was a failure to place safety at the heart of the system. A key finding was that governance, accountability and oversight mechanisms are confused and when they fail harm is more likely to happen repeatedly and over prolonged periods of time, with learning less likely to take place.

She came across:

• A lack of clarity on review processes, with variable quality of local reviews, limited follow up on actions and slow or no detection of emerging risk. She described the system of investigations as “almost impenetrable”. Families spoke of a sense that internal investigation teams were “marking their own homework” and that NHS Trust leadership prioritised reputational protection over learning. She was told of long delays in communication and generic apology letters. Baroness Amos was concerned that, despite numerous types of investigations, they were failing to drive improvements and make meaningful differences to the safety and quality of care delivered. She noted there were no robust systems for ensuring that the outcomes of investigations were routinely integrated into clinical or operational practice. Her panel found a “system that appears to be unable to learn from its mistakes”.
• Adversarial responses after harm with complex complaints routes, unclear accountability and too little openness, lack of apology and engagement. She saw a clear need to professionalise the role of healthcare investigators supported by clear competencies and consistent standards. Concern was expressed about families involved in more than one process having to repeatedly retell their experience.
• Poor working culture, including staff being fearful of being blamed when things went wrong, with a strong sense that senior leaders did not take responsibility and were not accountable. From reviews of trust documentation Boards were not “sufficiently curious”.

The investigation also reviewed recommendations from previous inquiries into Morecambe Bay, East Kent, and Shrewsbury and Telford. Further details are set out in Annex 3 (pages 115–137).

The National Maternity and Neonatal Recommendations Register contains more than 700 recommendations, many of which overlap. Overall, 895 recommendations were identified between 2014 and 2025.

Baroness Amos refers to HSSIB saying that the inability to implement recommendations effectively can perpetuate known risks, compound patient harm, undermine public confidence and limit the healthcare’s system to learn and improve. 

The investigation concluded that the effectiveness of recommendations depends not only on what is recommended but how recommendations are designed. It heard of “investigation fatigue” and observed that implementation is not a one-off activity but an ongoing process requiring sustained focus over time.

Baroness Amos made eight recommendations to address systemic failings (pages 13–22). Each requires action within six to 12 months. They include:

• Improving how the system responds and learns when something goes wrong. This included:
  • Families must have the right to request a Trust commissions an independent investigation.
  • A national specialist training programme to equip all investigation staff with the skills and protected time needed to carry out reviews and investigations to a consistently high standard.
  • Learning from investigations and reviews must be systematically shared at national and regional level.
  • CQC must include the assessment of the quality of investigations in their regulatory framework.
• Improving system governance and accountability structures and regulatory oversight.
• Creation of a new statutory role of Maternity and Neonatal Commissioner. Their role, amongst other things is to design a new Modern Service Framework ensuring systems:
  • Consistently apologise and acknowledge mistakes.
  • Transform processes if things go wrong to embed accountability.

She also called for:

• A government response to the 2019 consultation seeking views on introducing coronial investigations of stillbirth cases.
• The commissioning and publication of a report examining the benefits and drawbacks of an alternative compensation scheme for adverse events in maternity and neonatal services with the aim of promoting less adversarial relations between Trusts and harmed or bereaved families and promoting better learning from adverse events.  This was generated given the cost of settled claims relating to cerebral palsy or brain damage increased by 63% or £599m between 2016/17 and 2024/25 to £1.6bn. This is four times higher than the costs from the next specialty. 62% of the total clinical negligence provision (£60bn) relates to maternity.

On the day of publication, Sir Jim Mackay issued a 10-point urgent maternity and neonatal plan, placing emphasis on how organisations respond when care falls short. The measures call for greater openness, compassion and candour in the handling of patient safety incidents, complains and concerns. It said that NHS England will work with trusts, in alignment with the work of the national taskforce, to develop a blueprint for how organisations and leaders can respond with more humanity and compassion when things go wrong with a patient’s care.

Comment

We would suggest that good governance would mean that such a review by boards should not necessarily stop at maternity and neonatal services and should not be limited to NHS Trusts and that the wider points within the report should be digested by those operating across the piste.

This week, trusts were asked to complete a baseline assessment against the 25 requirements in the newly published Maternity and Neonatal 10-Point Plan assurance process by 25 September, followed by a progress update on 31 December 2026.

In the context of risk and learning this includes:

• Does the Trust have PSIRF embedded within the Maternity and Neonatal services through clearly defined governance processes? Is the learning, any actions and outcomes regularly reviewed, shared with women and families and routinely monitored at Trust Board level through Board Safety reporting?
• Does the Trust review complaints and concerns thematically, with learning actions and improvement plans monitored for impact? Are the themes and learning routinely reported to the Trust Board.
• Trusts must also provide evidence that robust duty of candour processes are in place.

For more information, please get in touch with our health and care team.

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