The recent Ockenden Report published Donna Ockenden’s reviews into maternity services at Nottingham University Hospitals NHS Trust and highlighted the need to make change across the nation’s maternity services. I wrote about that review here.
Very shortly after came Baroness Amos’ call echoing many of the same sentiments. I have referred to it as a second national call but in reality it is better termed the second national call of 2026. It is most certainly not the second ever call for change, it is one in a line of many reviews and inquiries regarding standards of care in the NHS.
The difference: this report was based on a review of the national maternity and neonatal services as a whole. A rapid review began in 2025 from which an Interim Report was published with the critical findings. This further in-depth review aimed to delve into the issues more and to make recommendations on how to make the changes designed to fix the problems identified.
The final report has been released and the concerns and issues found are almost identical from the side of the women, birthing people and families using the services. There is the added layer of additional evidence from the staff side indicating that whatever messages are shared at the top level as to what standard services should be at, this does not seem to bleed through and reach the corridors of hospitals themselves. Staff raising concerns and fears around culture, poor clinical environments, lack of breaks and rest, being stretched too thin and feeling that they cannot own up to mistakes and have senior staff take responsibility and be held accountable where the problems stem from higher up. These are all messages that reflect the difficulties the patients have with understanding what has gone wrong when the care provided to mothers and babies fails or falls below acceptable standards, and they are left living with the harm caused in often tragic and traumatic consequences.
What has this Review recommended?
Baroness Amos has recommended the following changes:
- Create a statutory Maternity and Neonatal Commissioner to lead the systematic changes needed.
- Take action to listen to the voices of women, birthing people and families within 12 months.
- Drive improvement, within 12 months, on the quality, transparency, oversight and accountability of investigations and ensuring that learning is captured and acted upon when things go wrong.
- Design a Modern Service Framework for maternity and neonatal services within 12 months and roll it out within 18 months.
- Treat racism, discrimination and inequality as a critical maternity safety issue within 12 months with work starting immediately.
- Clarify existing system governance, oversight and accountability structures and improve the effectiveness of regulatory oversight within nine months.
- Work with colleges, universities, post-graduate educators and others to improve culture and teamworking and to strengthen leadership at all levels within 12 months.
- Deliver estates and digital systems that are fit for modern maternity and neonatal care with 12-month, 5-year and 19-year investment commitments and implementation deadlines.
The scale and enormity of these recommendations is clear. What is less clear is how these changes will look and work on the ground and the clear risk that changes implemented in haste will in practice work against the issue they set out to fix. Some of these issues are systemic failings, some relate to clinical mistakes and errors, and others are cultural changes needed across organisations. The ability to deliver these changes is even less clear – it will take investment, resources and time as Baroness Amos concedes and yet it has become very clear that it needs to happen urgently.
The Task Force has already been established and the Commissioner in the process of being appointed. We must hope that this most recent call for change has more effect than all the previous ones and is capable of effective delivery quickly.