The Government’s response to Baroness Amos’ review marks a major intervention, but the real test will be whether national standards, accountability and culture change reach every trust.
The creation of a Maternity and Neonatal Commissioner could give families the national voice they have long needed, but only if the role has the authority to force action.
A system that has failed to listen
The Government’s decision to appoint England’s first Maternity and Neonatal Commissioner is the most visible response yet to Baroness Valerie Amos’ landmark investigation into maternity and neonatal services. It is also an acknowledgement that the current system has too often failed to listen, failed to learn, and failed to act with the urgency that women, babies and families deserve.
Published on 30 June, the Government response accepts the need for a new independent commissioner to speak up for women, babies and families, co-chair the National Maternity and Neonatal Taskforce with the Secretary of State, and help drive national change. It also promises a National Action Plan in December 2026, £41 million in additional safety funding for maternity and neonatal facilities, new national standards for maternity triage, the rollout of the Perinatal Equity and Anti-Discrimination Programme, and 1,000 temporary roles to support newly qualified midwives into the NHS.
The scale of the problem set out by Baroness Amos is stark. Her investigation heard directly from women, families and staff, alongside local investigations into 12 NHS trusts, and describes a system that is fragmented, overly complex, too slow to learn and too inconsistent in how it responds when families raise concerns. The report identifies recurring failures to listen to women and families, racism and discrimination, weak accountability, workforce pressure, poor culture, and outdated estates and digital systems.
Pointing to the findings of racial discrimination in the report, Baroness Lawrence of Clarendon OBE, Chair of the Race Equality Engagement Group, said:
“I would also like to place on record my thanks to Baroness Amos for leading this vital and timely report.
“The findings highlighted by Baroness Amos’ important report reveal the deeply entrenched racial inequalities that exist in maternity and neonatal services in England.
“Racism and discrimination have no place in our health service. The fact that women have received worse care due to their race or background is totally unacceptable and cannot continue. I look forward to the government’s urgent work to now deliver the manifesto commitment to set a target for tackling the maternal mortality gap.”
Kate Brintworth, Chief Midwifery Officer for England, said:
“Too many women, babies and families have been harmed, bereaved or badly let down by maternity care, and too often women and families who raised concerns were not listened to.
“This has to change. Women and families must be taken seriously when they say something is wrong, and staff must feel able to speak up when they are worried about safety.
“The NHS is determined to address this quickly and we will work with the new Maternity and Neonatal Commissioner to achieve this. NHS leaders are also coming together today to set out how immediate actions can be taken across all maternity and neonatal services in England to improve safety and the support and care offered to women and families.
“I know recent reports will be deeply worrying for women and families, but please continue to speak to your midwife or maternity team if you have any concerns. They understand and want to make sure you have the care and support you need.”
Commenting on the report, Secretary of State for Health and Social Care, James Murray, said:
“For too long women, babies and families have been failed by a system that didn’t listen. Their stories are heart-breaking and demand action.
“I am grateful to Baroness Amos for her work on this landmark review, which is a turning point. Appointing the UK’s first ever Maternity and Neonatal Commissioner will drive lasting change and make sure women and families are never ignored again.”
Why the commissioner matters
The central recommendation is a Maternity and Neonatal Commissioner, accountable to Parliament, with responsibility for holding the system to account, championing the voices of women and families, and overseeing a new Modern Service Framework. That framework would set national standards for safe, consistent and compassionate care, moving maternity policy away from guidance that can be unevenly applied and towards clearer expectations for what every service should provide.
But this cannot be treated as a new discovery. Dame Donna Ockenden’s Nottingham review, published last week, underlined the same uncomfortable truth: many of the issues described were already known. The independent review into maternity services at Nottingham University Hospitals NHS Trust examined more than 2,500 family cases, involved more than 160 reviewers, held meetings with more than 500 families, and heard from more than 830 current and former staff.
Ockenden’s own reaction is telling: the Amos findings were nothing she did not already know. That is the central challenge for ministers, NHS England, regulators and trust boards. The country does not lack evidence of what is wrong. It lacks a reliable mechanism for turning evidence into safer care.
Maternity Advisor, Michelle Welsh MP said:
“I am pleased that a Maternity and Neonatal Commissioner role will be established, and I look forward to seeing a robust appointment process take place.
“I want to thank Baroness Amos for her hard and thorough work on this report, as well as those who have contributed to this effort – most importantly the families who have shared their experiences, alongside the organisations that have supported this work.
“It is now vital that we work together to deliver meaningful and lasting improvements in maternity care centred around safety and compassion.”
A warning from wider NHS culture reviews
That warning has also been echoed by Curia Health, Care, and Life Sciences Research Group Advisory Board member, Professor Mike Bewick, whose review into culture at University Hospitals Birmingham found that fear, bullying and reluctance to speak up can have a direct impact on patient safety.
Reflecting on the Amos Review, Professor Bewick said:
“The Amos Review is a stark reminder that we cannot continue to accept incremental change in the face of repeated failures. Its findings make clear that improving maternity care requires fundamental, system-wide reform, with courageous leadership and robust accountability at every level. The recommendation to establish an independent Maternity Commissioner is a significant opportunity to provide the national leadership, oversight and challenge needed to drive sustained improvement and ensure recommendations are translated into action. Women, babies and families deserve more than repeated reviews – they deserve a system that learns, acts and is accountable for delivering safe, equitable and compassionate care.”
His intervention matters because maternity safety is not only a maternity issue. It is a test of whether the NHS can create cultures where staff are able to speak up, families are believed, leaders are held to account and warning signs are acted on before harm becomes scandal.
Triage as a test of delivery
The most immediate area for reform is triage. Baroness Amos describes maternity triage as increasingly becoming the A&E service for pregnancy, where warning signs should be identified early. The report recommends dedicated midwife resource, access to senior clinical decision-makers, board-level oversight, a national triage standard within 12 months, and quarterly publication of triage performance data.
“Racism and discrimination have no place in our health service.” Baroness Lawrence
This is where policy becomes practical. A woman who calls or arrives with concerns should not depend on local staffing patterns, estate pressures or whether a unit has chosen to prioritise triage that day. National standards will only matter if they are measured, published and treated as core patient safety indicators.
The lessons for maternity safety
The lessons from Amos and Ockenden are clear. First, listening must be treated as a clinical safety function, not a soft measure of patient experience. Second, accountability has to be built into the system before harm occurs, rather than reconstructed through inquiries afterwards. Third, racism, discrimination and poor culture must be treated as safety risks, visible in board papers, regulatory judgements and workforce planning. Fourth, national standards must be matched by local delivery, with consequences where services fail to improve. The analysis is therefore simple but uncomfortable: another review will not fix maternity care unless the system is forced to act on what it already knows.
There are risks. Some campaigners have warned that concentrating responsibility in one commissioner could raise expectations that one person cannot meet, while others continue to argue for a statutory public inquiry. Baroness Amos has defended the commissioner model as an independent voice for women and families, and has argued that urgent change should start now rather than wait years for another inquiry.
Chief Executive of UK Healthcare and Life Sciences Innovation (UKHLSI), Jo Bekis said:
“The Amos Review is a stark reminder that we cannot accept a maternity system where avoidable harm continues to occur. Its findings reinforce the urgent need for meaningful, system-wide change that puts safety, compassion, accountability and the voices of women and families at the heart of maternity care.
“Every woman deserves high-quality care, every family deserves to be heard, every newborn deserves nothing less than safety and every avoidable tragedy must drive us to act now.”
The December action plan must be specific
The Government should be judged on whether it has not only accepted the headlines of the Amos report, but also on how it builds the machinery to deliver them. By December, the National Action Plan must show who is responsible, what will change first, how progress will be measured, what happens when trusts fail to improve, and how families will know that their voices have led to action.
Maternity care is often described through the language of trust. That trust has been badly damaged. Rebuilding it will require more than empathy after harm has occurred. It will require a system that listens before harm happens, acts when warning signs appear, tells the truth when things go wrong, and treats safety, equity and compassion as core measures of performance.