A national inquiry has strongly criticised the NHS maternity system in England, saying it is “not set up to deliver consistently safe, high-quality and compassionate care”.
Baroness Valerie Amos, who chaired the government-commissioned review, found “unacceptable racism and discrimination embedded within the system” and said that “as a country… we cannot continue like this”.
She recommended eight changes to overhaul the system, including the appointment of a maternity commissioner with a “relentless focus” on improving care.
Her independent findings come days after a review into maternity care in Nottingham found hundreds of women and babies had been harmed by poor care.
Health Secretary James Murray said he was unable to confirm a timeline for the appointment of the maternity commissioner role, but told BBC Breakfast his team would “move as quickly as we can”.
Controversy has surrounded the publication of the final Amos report after one of the country’s leading maternity investigators resigned over its conclusions.
Dr Bill Kirkup, who investigated maternity services in Morecambe Bay and East Kent, is understood to have disagreed with Baroness Amos over her finding that a push for normal birth, including denying women caesarean sections, was not prevalent nationally.
A series of scandals
The National Maternity and Neonatal Investigation, external was set up last summer by the then-health secretary, Wes Streeting.
The aim to was produce a report to drive through improvements across England after a series of maternity scandals undermined the trust of many families in the NHS.
Baroness Amos and her team heard from more than 450 families and visited 12 NHS trusts to understand what change was needed.
The key failing they identified was an unwillingness to listen to women and families, leading to poor outcomes. There was a lack of a consistent standard of care, with large variations across the health service.
The system is “fragmented, overly complex and too slow to learn and improve,” Baroness Amos noted in her report.
One of the immediate actions being urged on maternity units is to overhaul their triage service, which Baroness Amos described as “increasingly becoming the A&E service for maternity”.
As part of that, midwives should be dedicated to answering calls and providing timely advice, while women should be offered a face-to-face appointment if they remain concerned. If these changes are made, the report says, “lives will be saved and harm reduced”.
Meanwhile, racism and discrimination must be treated as a critical safety issue, the inquiry found, requiring urgent intervention including gathering granular data on unequal outcomes that is escalated to board level when patterns emerge.
Speaking to BBC Radio 4’s Today programme, Baroness Amos said the system was “not fit for the now and it is not fit for the future”.
“We need national standards to frame maternity and neonatal care against which we can then test how trusts are doing, how care is being delivered,” she added.
Baroness Amos acknowledged calls for a statutory public inquiry that would compel senior figures at under-fire hospital trusts to give evidence. But she is not supportive of such a move.
“Statutory public inquiries take a very, very long time,” she said.
“From the work that I have done and from the conversations that I have had with families, I don’t at the moment see that there is a need for a statutory public inquiry, but that’s not a decision for me to take.”
The eight recommendations are:
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Appoint a national Maternity and Neonatal Commissioner to drive change
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Listen to the voices of women, birthing people and families
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Improve how the system responds and learns when something goes wrong
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Sets out national standards to consistently achieve high-quality care.
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Tackle racism, discrimination and inequality
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Improve governance and accountability structures and regulatory oversight
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Improve culture and teamworking, and strengthen leadership at all levels
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Deliver digital systems and buildings that are fit for modern care
‘Huge missed opportunity’
Bereaved parent Rhiannon Davies, who campaigned for a review into maternity failings in Shrewsbury and Telford after the avoidable death of her daughter Kate in 2009, said she broadly welcomed the report’s findings.
“One area where I think the report is particularly strong is that it reframes listening to women as a patient safety issue rather than simply an issue of patient experience,” she said.
“The report also places considerable emphasis on maternity triage. Again, I think this has huge potential – but only if we get it right.”
But Dr Kim Thomas, who runs charity the Birth Trauma Association, described the report as a “huge missed opportunity” that does not sufficiently reflect families’ experiences.
“Many of us were hopeful that finally this would mean harmed women and families would be listened to and that change would be forthcoming,” she said.
“It is devastating, therefore, to see that so little of what women told Baroness Amos is reflected in the report.”
She notes injuries caused by forceps deliveries and the impact of post-traumatic stress on women and their partners are not mentioned, and argues the experiences of staff are given too much weight in the report compared to the experiences of patients.
Helen Gittos, whose baby daughter Harriet lived for a week after sustaining a brain injury under the care of the East Kent NHS Trust in 2014, has mixed feelings about the report.
Gittos is chair of the Family Expert Reference Group for the National Maternity & Neonatal Taskforce and thinks many of the recommendations will make a real difference if they are implemented “fearlessly in a way that tackles the core issues and does not water them down”.
But she was “dismayed” when reading the report’s depiction of East Kent, one of the selected trusts, which she felt was “overly positive”.
“If improvement in an individual trust cannot be sustained even with intensive support from national teams it indicates that the support they are giving is not working,” she added.
Meanwhile, the Maternity Safety Alliance (MSA), which represents families who are calling for a public inquiry said the report “failed to address core issues at the centre of maternity failings”.
The MSA said the recommendation for a maternity commissioner in the format proposed by Baroness Amos was “fundamentally dangerous”. It added: “This person will not be meaningfully independent and will not be able to create real change.”
Emily Barley, the group’s co-founder who lost her daughter during labour at Barnsley hospital four years ago, said the proposal was “designed to make headlines but not actually make the change we need”.
“Concentrating all of the power and responsibility for turning around maternity services in the hands of one person is, in my view, just insane,” she told the Today programme.
The Department of Health and Social Care said it would take “urgent steps” in response to the “landmark” investigation.
It also pledged to publish a national action plan in December to overhaul services, alongside £41m investment to improve safety in maternity and neonatal care.
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