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Carla Duprey, Clinical Negligence Solicitor, shares her thoughts on Baroness Amos' final report.
Baroness Amos’ final report once again highlights the persistent failure to listen to families and the tendency for their concerns to be dismissed during childbirth and neonatal care. The report’s opening paragraph powerfully captures the stark realities of families’ experiences:
‘Anticipation and joy turned into pain, distress and trauma. Questions left unanswered. Responsibility and accountability denied. Not heard. Rebuffed. Dis-missed. Ignored. Psychological harm repeated over and over with the constant retelling of experiences. And running through it all the feeling of justice denied, for self and for others. Because mistakes continued to be made. Learnings were not shared and the system did not change fast enough’.
These words paint a picture of the profound impact that poor maternity and neonatal care can have on families. They reinforce the report’s central message: that too many families continue to feel unheard, unsupported and let down by a system that has been slow to learn from past mistakes and to implement meaningful change.
Baroness Amos has built on the recommendations made by previous inquiries and investigations, setting out a programme of system-wide reforms aimed at ensuring that fundamental changes are made to maternity and neonatal services as quickly as possible. One of the key recommendations is the creation of a statutory National Maternity and Neonatal Commissioner, who will oversee the implementation of the report’s recommendations. Effective oversight and accountability will be crucial to the success of this process. Baroness Amos has also established clear timescales for implementation, with most recommendations expected to be delivered within 12 months. The emphasis on prompt action is welcome, reflecting the urgency of the issues identified. The proposed Commissioner should play a vital role in ensuring that organisations take the necessary steps to meet these deadlines and deliver meaningful improvements for families.
The Government has already responded to the report by issuing a press release, , confirming a number of immediate commitments including:
- A Commissioner will be appointed to speak up for women, babies and families
- A National Action Plan will be published in December 2026 to overhaul services and drive long-term change
- An additional £41 million investment will be made to improve safety at maternity and neonatal facilities
- New standards for maternity triage will be implemented.
We will now have to wait and see how the Government and the wider maternity system respond over the coming year. While the report and the Government’s initial commitments are encouraging, the real test will be whether these recommendations are implemented in full and lead to meaningful improvements in the experiences and outcomes of women, babies and families. Given the findings of Baroness Amos’ report, continued oversight, accountability and transparency will be essential to ensure that the opportunity for lasting change is not missed.
Carla Duprey, Solicitor
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