Baroness Amos has called for an urgent overhaul of NHS maternity triage services in England after a damning review found that pregnant women’s concerns were repeatedly dismissed, leading to avoidable baby deaths. The review, which interviewed 450 families and received 10,500 written responses, concluded that the NHS in England “is no longer fit to consistently deliver high-quality, compassionate care” for all mothers and babies.
Key Findings: Dismissed Concerns and Avoidable Harm
The review highlighted that women who called hospitals with concerns such as reduced foetal movement, abdominal pain, or bleeding were often rebuffed until it was too late. Baroness Amos stated: “Words cannot describe the pain, suffering and trauma I saw and heard time and time again when talking to women and families about their experiences of maternal and neonatal care in England. Anticipation and joy turned into pain, distress and trauma. Questions left unanswered. Responsibility and accountability denied. Not heard. Rebuffed. Dismissed. Ignored.”
The report described maternity triage as “the A&E service for pregnancy related concerns,” where time-sensitive clinical decisions are made. It noted that “inappropriate decisions or delays can have serious and irreversible consequences.”
Systemic Failures and Staffing Issues
The review team visited 12 NHS trusts and gathered input from over 9,000 staff through surveys and interviews. It found that wards and infrastructure were often “not fit for purpose,” with overcrowding common and postnatal wards lacking privacy. The review also identified racism and discrimination as “embedded throughout the maternity and neonatal system.”
One woman recounted waiting in a corridor for four hours: “They said there's not enough room in the triage room, so we had to go and wait in the corridor… we were put in a [triage] bed at 2.10am and she was concerned with the baby’s heartbeat, so I was put on a CTG, and then just left. We were told that a clinician or a consultant or someone would come and have a look but then we were just left. I could see it [the baby’s heartbeat] going down, and down, and down, and then it was like going down, below 90, and we were just left. They said she wasn't delivered when she should have been.”
Recommendations and Government Response
Baroness Amos recommended the creation of a statutory national Maternity and Neonatal Commissioner, accountable to Parliament, to drive reform and set minimum standards. The government has accepted this. Health Secretary James Murray said: “For too long women, babies and families have been failed by a system that didn’t listen. Their stories are heartbreaking 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.”
The review also called for families to have the right to an independent investigation of their care when things go wrong, and for senior doctors to be on rotas 24/7. Murray has committed to publishing an action plan based on the findings by December.
Context: A Series of Scandals
The Amos review follows a string of local maternity scandals, including a report by Donna Ockenden on failings at Nottingham hospitals, which found that more than 500 babies and mums suffered harm or died. Similar reviews have been conducted at Shrewsbury and Telford, East Kent, and Morecambe Bay, with ongoing investigations at Leeds Teaching Hospitals and University Hospitals Sussex.
Baroness Amos said: “I still find it shocking that women and babies have been harmed or have died, sometimes as a result of failings in the maternity or neonatal care provided. We are a wealthy country. It should not happen. We heard from families who have lost friends or family members who were new parents or parents-to-be in tragic circumstances. It has taken courage to repeat painful and traumatic experiences. Some families told us they were prepared to share these experiences so as to prevent this happening to anyone else, ever again.”
