Lessons from the Amos Review and the Nottingham Maternity Review: why maternity care in England must change

What did the Nottingham Maternity Review examine? 

The Nottingham review, whose final report was published on 24 June 2026, examined maternity and neonatal services provided by Nottingham University Hospitals NHS Trust, also referred to as NUH. Led by Donna Ockenden, an experienced midwife who has led other independent maternity investigations, this is the largest investigation into NHS maternity services ever undertaken.  

It examined more than 2,500 cases involving mothers and babies who suffered death or serious harm between 2012 and 2025. The review concluded that 520 of them experienced serious avoidable harm, while many maternal and neonatal deaths could have been prevented with appropriate care.  

The report described a toxic workplace culture characterised by bullying, poor leadership, failures to investigate incidents, and repeated dismissal of women's concerns. These failures were not isolated incidents but reflected deep-rooted organisational problems that persisted for more than a decade.  

It also highlighted that: 

“Many of the issues described in this Report have been known about at NUH since at least 2010, including: insufficient staffing and funding across perinatal care settings; the inability of staff to undertake even basic (often, mandatory) training; a persistent failure to listen to and believe mothers and fathers; and a corresponding failure to investigate, and therefore learn from, mistakes.” 

Perinatal care refers to the care provided to women and babies during pregnancy, childbirth and the period shortly after birth. 

What is the Amos Review? 

The Amos Review broadened this picture to a national level. Led by Baroness Valerie Amos, the independent national investigation examined the quality and safety of maternity and neonatal services across England. Rather than focusing on one NHS Trust, it considered evidence from families, healthcare professionals, national organisations and previous investigations into services at a number of NHS Trusts. 

The opening words of the Amos report’s foreword, published on 30 June 2026, strike particularly hard:  

“Words cannot describe the pain, suffering and trauma I saw time and time again… anticipation and joy turned into pain, distress and trauma. Questions left unanswered. Responsibility and accountability denied. Not heard. Rebuffed. Dismissed. 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. I wanted to understand how this was still possible in England in the 21st century.”   

The review drew from investigations across 12 NHS Trusts and concluded that maternity and neonatal services across England are "no longer fit for purpose."  

Women frequently reported feeling ignored, dismissed, or blamed when raising concerns about their own health or their baby's wellbeing. The review also identified inequalities in care, particularly affecting women from Black, Asian, and other minority ethnic backgrounds. It highlighted that discrimination can directly affect how concerns are assessed, how quickly treatment is provided and, ultimately, the safety of women and babies. It should therefore be treated as a patient safety issue, rather than solely as a matter of equality. 

Why listening to women is a patient safety issue 

A central theme running through both reports is the failure to listen to women. Families repeatedly described situations where concerns about reduced fetal movements, pain, bleeding, or deterioration after birth were minimised or ignored.  

Reduced fetal movements means that a pregnant woman has noticed her baby moving less frequently, or that the baby’s usual pattern of movement has changed. This can sometimes be a warning sign that the baby needs to be assessed urgently. 

In many cases, delayed recognition of complications contributed directly to avoidable harm. Both reviews argue that listening to women should be regarded as a core clinical safety intervention rather than simply an aspect of compassionate care. Women are often the first to recognise that something has changed in their own health or their baby’s condition, so taking their concerns seriously can be essential to identifying complications and providing treatment promptly. 

How workplace culture can affect maternity safety 

Another shared finding is the impact of organisational culture, meaning the behaviours, attitudes and working practices that influence how an organisation operates.  

The Nottingham review identified bullying, intimidation, and poor leadership that discouraged staff from speaking up about safety concerns. Similarly, the Amos Review concluded that maternity services require a fundamental cultural shift towards openness, accountability, and learning.  

Improvements in clinical practice are unlikely to be sustained without psychological safety for staff, meaning that they can raise concerns, report mistakes and challenge unsafe decisions without fear of bullying, blame or retaliation, as well as genuine engagement with patients. 

The effect of staffing shortages 

Staffing shortages also feature prominently in both reports. Chronic workforce pressures have left many maternity units struggling to provide safe, personalised care.  

Staff described working under significant pressure, with insufficient time to monitor women appropriately, escalate concerns, or provide emotional support. The reviews argue that improving staffing levels is essential if maternity services are to deliver consistently safe care. However, staffing numbers alone will not address the problems identified. Staff must also receive appropriate training, leadership and support, with clear systems in place for responding to concerns. 

What changes have been recommended? 

Despite the seriousness of their findings, both reports offer a roadmap for improvement. The Nottingham review sets out immediate and essential actions for Nottingham University Hospitals NHS Trust and for maternity services nationally, including stronger governance to improve how the safety and quality of services are overseen, better staff training, improved incident investigations, and greater accountability.  

The Amos Review recommends more fundamental national reforms, including increased transparency, stronger leadership, and sustained investment in maternity services.  It also calls for the creation of a statutory Maternity and Neonatal Commissioner, who would independently oversee improvements and help hold healthcare organisations and national bodies accountable, as well as the development of a Modern Service Framework to establish consistent national standards for safe and personalised maternity and neonatal care across England. 

The report states that such a framework would provide “a consciously designed, nationally consistent blueprint for what safe, personalised maternity care should look like, and a clear roadmap and accountability mechanisms for how to get there.” 

Why these findings matter across England 

Together, these reports demonstrate that the challenges facing maternity care are not confined to one hospital or one NHS trust. Instead, they reveal longstanding systemic issues that require coordinated national action.  

The experiences of thousands of families show the devastating human consequences when healthcare systems fail to respond to warning signs, learn from mistakes, or place women and babies at the centre of care. 

Turning recommendations into meaningful change 

The publication of these reviews should represent more than another series of recommendations. Their lasting impact will depend on whether healthcare organisations, policymakers, and professionals translate their findings into meaningful, measurable improvements.  

Restoring public confidence in maternity services will require not only investment and structural reform but also a commitment to compassionate, respectful, and evidence-based care where every woman is listened to and every baby's safety is prioritised.   

In her concluding remarks, Donna Ockenden emphasised that safer maternity care remains achievable, but only if the findings lead to sustained action:  

“I firmly believe that safe, compassionate and equitable perinatal care is still achievable in Nottingham and across England, but only if there is unwavering commitment to accountability, learning, transparency and kindness at every level of the system. We owe it to every mother, every baby and every family whose terrible experiences are recorded here that they are never repeated. Now is the time for focused, collective action to ensure sustained improvement that will allow every woman in England to have confidence in the care that they will receive when giving birth in the NHS.” 

What needs to happen now to make maternity care safer? 

For Kate McCue, a Partner in our Medical Negligence team who represents families affected by failures in maternity care, the findings of both reviews reinforce the urgent need to ensure that lessons from previous investigations lead to lasting change. 

Kate said: ‘’What is particularly difficult about the findings of these reviews is how familiar many of the problems are. Families have repeatedly spoken about not being listened to, concerns being dismissed, failures to recognise when a mother or baby is deteriorating, and mistakes not being properly investigated or learned from. 

'’These reports make clear that improving maternity care cannot be achieved through recommendations alone. There must be meaningful accountability and measurable action, with families listened to at every stage and healthcare professionals supported to raise concerns when they believe care is unsafe. 

'’In my work representing families affected by maternity care failures, I see the profound and long-term consequences that avoidable harm can have, not only for mothers and babies but for entire families. No family should have to fight to be heard after something has gone wrong, particularly when many have already tried to raise concerns before harm occurred. 

'’The publication of these reviews must now be followed by sustained action. The real measure of their impact will be whether the same failures stop being repeated and whether women and families can have confidence that when they raise concerns, they will be listened to and taken seriously.'’ 

If you or a loved one has been affected by failures in maternity care, our specialist Medical Negligence team can help you understand your legal options. You can call us on 0808 149 9561 or request a callback at a time that suits you. 

To find out more about making a medical negligence claim, click here.