The Government has announced the creation of a national statutory Maternity and Neonatal Commissioner following a damning review by Baroness Amos, which uncovered 'heartbreaking' failures across 12 NHS trusts. The review, based on evidence from more than 450 families and 10,500 public responses, identified persistent issues including women not being listened to, racism on wards, and victims being gaslit.
Baroness Amos's Findings
Baroness Amos, a former Labour cabinet minister, concluded that maternity care in England is 'fragmented, overly complex and too slow to learn and improve'. She stated: 'Every avoidable death of a baby, a woman, is one too many. Every instance of avoidable harm is one too many. The emotional toll and cost to families is indescribable. As a country, as a community, we cannot continue like this.' The 261-page report highlighted that such 'shocking' failures 'should not happen' in a wealthy country.
Families' Experiences
Women who spoke to the inquiry described feeling dismissed when they begged for help from medical staff. One woman said she had to become a medical and legal expert while grieving the death of her baby. Another said: 'What should’ve been five years of grieving was in fact five years of fighting for the truth.' The report also noted poor leadership and bullying by senior staff, echoing issues from the recent Nottingham maternity review.
Government Response and Funding
Health Secretary James Murray said the report would be a 'turning point' and 'drive lasting change and make sure women and families are never ignored again'. The Government accepted the recommendation to create a statutory national Maternity and Neonatal Commissioner and announced £41 million extra investment to tackle urgent safety risks in neonatal facilities, on top of £145 million committed since April 2025. The review found that some hospitals and wards were outdated, overcrowded, and 'not fit for purpose'.
NHS Commitment
Kate Brintworth, Chief Midwifery Officer for England, said the NHS was 'determined to address' problems quickly. She added: '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.'
Language Controversy
The report faced criticism for using the term 'birthing people' more than 100 times, which encompasses anyone giving birth, including transgender men. Fiona McAnena, director of campaigns at sex-based rights charity Sex Matters, called the phrase 'a disgrace', adding: 'The pain and loss is felt by mothers and fathers, but only women can become pregnant and give birth. To pretend otherwise shows shameful disregard for women harmed by these systemic failures in the NHS. They are all mothers, not “birthing people”.' A note in the report said the language 'seeks to centre the experiences of women and mothers, while also recognising that not everyone who is pregnant, gives birth or uses maternity and perinatal services identifies as a woman or mother'.
