The Amos Report: Another Inquiry Or Real Catalyst For Change?

The Amos Report raises a familiar question: will this latest inquiry finally drive meaningful improvement in maternity care, or simply repeat lessons already identified by previous investigations?

Background: Decades of Warnings

UK maternity services have been subject to repeated high-profile scrutiny for more than 15 years. Investigations into failures at Morecambe Bay, East Kent, Nottingham, Shrewsbury and Telford, and others have consistently identified avoidable harm, persistent inequalities, poor communication, inadequate listening to families’ concerns, fragmented care, and failures to learn and implement recommendations. Despite numerous inquiries and reviews, many of the same issues continue to recur across maternity services, raising concerns about the effectiveness of systemic improvement efforts.

The Better Births report (2016) set ambitious targets to reduce stillbirths, neonatal deaths, maternal deaths and brain injuries occurring during or shortly after birth. However, progress has been inconsistent. While improvements have been achieved in Some areas, declines have stalled or reversed in others, with certain mortality rates have risen in recent periods. The COVID-19 pandemic further exacerbated existing staffing and capacity pressures. Stark inequalities remain, with Black women approximately three times more likely to die in pregnancy or shortly after birth, with Black babies twice as likely to be stillborn.

In June 2025, the government launched the independent National Maternity and Neonatal Investigation, chaired by Baroness Valerie Amos. It examines 12 trusts with concerning safety records, while taking a national, whole-system view.

Key Milestones

• August 2025: Baroness Amos appointed
• December 2025: Initial reflections
• 26 February 2026: Interim Report with strong systemic findings but no final recommendations
• 30 June 2026: Final Report published, setting out national recommendations and a proposed programme of reform

The Interim Report in Brief

The February 2026 interim report concluded that maternity and neonatal services are “not working for women, babies, families, or for staff” and identified six key contributing factors to the pressures and failures within the system:

• Capacity pressures
• Culture and leadership issues
• Racism and discrimination
• Poor responses and lack of accountability when things go wrong
• Quality of estates
• Workforce challenges

The report highlighted families being disregarded, not listened to, and left without proper explanations or support, leading to self-blame, trauma and long-term harm. Persistent ethnic and socioeconomic inequalities were also emphasised.

The Final Report: Continuity of Findings

The final report reinforces these themes and confirms the scale of the challenge. Baroness Amos states:

“Every avoidable death of a baby, a woman, is one too many. Every instance of avoidable harm is one too many.”

The report concludes that maternity care remains fragmented, overly complex, and too slow to learn and improve.

While new national recommendations have been proposed, the underlying issues identified remain consistent with previous inquiries.

Commissioning Oversight Failures (CCGs to ICBs)

A recurring finding across numerous inquiries has been weak commissioning and inadequate oversight. Clinical Commissioning Groups (CCGs), which replaced Integrated Care Boards (ICBs) on 1 July 2022, were intended to hold NHS trusts to account, use data intelligently, and drive service improvement. In practice, these bodies have often been criticised for:

• Insufficient oversight of known red flags and warning signs, including poor CQC ratings, high complaints, and staff concerns
• Prioritising financial performance over quality and safety
• Failing to intervene effectively or to ensure the implementation of recommendations

This sits within a wider accountability chain involving NHS trusts, regulators, and national bodies. Structural reorganisation has repeatedly failed to resolve the underlying challenges of accountability and effective implementation.

Relevance to Clinical Negligence Claims

From a legal perspective, the patterns identified by Amos are well recognised:

• Failures in listening to women and not acting upon their concerns
• Delayed recognition and a failure to escalate deterioration
• Inadequate investigation and learning when harm occurs
• Inequalities are amplifying the risk for certain groups

These are not merely isolated clinician errors, they are systemic issues that create the conditions for avoidable injury and patient harm. The costs to NHS Resolution continue to rise, reflecting not only the the human impact on patients and their families but also the growing financial burden on the system.

Looking Ahead

The publication of the final Amos report provides another opportunity to drive meaningful change. To succeed where previous inquiries have fallen short, its recommendations must address the underlying issues of accountability, organisational culture, workforce capability, and effective implementation, rather than focussing solely on further structural reform.

A central question is whether the mechanisms for accountability and enforcement are robust enough to drive change meaningful change across a complex and fragmented system. This is explored further in our companion piece, “Where Are the Teeth? Accountability Without Enforcement in NHS Maternity Care.”

Families and legal practitioners will be watching closely to see whether this becomes yet another report that gathers dust or a genuine catalyst for safer, more equitable maternity care.

Our Support

If you would like to discuss what happened to you with our friendly team of specialist solicitors, we can provide clear, compassionate and confidential advice about your legal rights following concerns regarding your maternity care, pregnancy, labour, delivery or postnatal treatment. We understand that complications during pregnancy or childbirth can have a significant impact on both parents and babies, and we are here to listen and support you.

There is no obligation to proceed with a claim, and an initial discussion with our team is entirely confidential.

References

• Independent National Maternity and Neonatal Investigation, Final Report and Recommendations (30 June 2026)
• Baroness Amos, published statement within the Final Report (30 June 2026)
• UK Government announcement on Maternity and Neonatal Investigation (2025)
• Previous maternity inquiries: Morecambe Bay (2015), Shrewsbury and Telford (2022), East Kent (2022), Nottingham Review (2026)
• Better Births: Improving outcomes of maternity services in England (2016)