The Amos review tells us nothing we did not already know

If the government intends for the Independent Investigation into Maternity and Neonatal Services in England to be the last word, we are in trouble. The inquiry, chaired by the Labour peer Valerie Amos, concludes that the system is “not set up to deliver consistently safe, high-quality and compassionate care”. It tells us nothing new. Amos recognises that women and families are frequently not listened to or treated with compassion, and that this leads to harm. But the voices of these families are surprisingly lacking from the report. The condition of hospital buildings and staff views are given equal – if not greater – weight than the experiences of those failed by NHS maternity care.

I have spent the past year talking with families across the country. Their lives have been forever changed. Their babies have died or been left with brain damage. Mothers live with physical pain, incontinence or psychological trauma. These experiences are not adequately reflected by Amos. In the case of birth injuries, they are absent altogether. The Birth Trauma Association charity brands the report a “huge missed opportunity”. The Maternity Safety Alliance group of bereaved families is similarly critical. The investigation “has left huge gaps in analysis and understanding of what has gone wrong in maternity care”, they say.

Amos’s eight recommendations are largely common sense. Women and families must be listened to; the NHS must respond better when things go wrong; racism and discrimination must be tackled; and culture must improve. But it is hard to see why this time they will be implemented, when for the past decade the NHS has failed to enact similar suggestions. 

On specific questions the review was asked to address – for example, whether coroners should investigate stillbirths (parents of stillborn babies currently have no recourse to independent investigation) – Amos has little to offer. The review agrees with concerns raised by the New Statesman about the unreliability of hospital investigations into baby deaths, but does not put forward detailed solutions. “All current investigation types must include independent challenge at every stage,” Amos argues. Currently these reviews require an independent person to take part in 60 per cent of cases. Likewise, Amos is highly critical of the hospitals’ regulator, the Care Quality Commission (CQC), but makes no concrete recommendations for its future. Amos’s chief recommendation (which has been accepted by the government), the establishment of a statutory national Maternity and Neonatal Commissioner, places enormous power and responsibility for change in the hands of a single person.

While every NHS maternity scandal over the past decade has highlighted the push towards so-called normal birth (vaginal births, without intervention) as contributing to unsafe care, Amos does not. “The quest for normal birth” contributed to the avoidable harm and deaths of more than 500 women and babies in Nottingham, Donna Ockenden said on 24 June. Yet Amos says her team “did not find that ‘normal birth ideology’ was currently widespread”. One of the country’s leading maternity investigators, Bill Kirkup, quit his role on the investigation over this conclusion.

The most damning details lay in 12 smaller, individual reports on the hospital trusts investigated as part of the national review. At Sandwell and West Birmingham NHS Trust, patients and staff are routinely subjected to racism and discrimination. “Life was cheap,” one staff member said of the prevailing attitude. Amos is concerned over the safety of women and babies at the trust. She voiced similar concerns over patient safety at Yeovil District hospital. But it is unclear what will change, now these units have been branded unsafe; there is no call to action.

At Oxford University Hospitals (OUH) NHS Foundation trust, Amos shared concerns uncovered by a joint investigation between the New Statesman and Channel 4 News, albeit in thin detail. Families were not listened to, she noted, and staffing levels were inadequate. The report expresses unease about OUH’s departure from national guidance to provide women with an extra scan at 36 weeks, and the impact this had on capacity to scan women at risk in late pregnancy.

OUH showed a “willingness to ignore national guidelines based on evidence in favour of what Oxford clinicians think is the better way”, Amos noted more generally. “Woe betide you if you challenge,” staff told her. Yet, Oxfordshire families tell me they feel “betrayed” by the review. Having shared “painful experiences of baby loss, brain injuries at birth and devastating physical and psychological harm to mothers” with Amos, “almost none” of it is reflected in the report.

I feel a sense of despair. There is so much more to England’s failing maternity system than is explored in the Amos review, or than was able to be examined in Donna Ockenden’s devastating four-year inquiry into Nottingham. Both reviews, like all those that have come before, came about because of tireless campaigning by families. The same is true of inquiries still to come in Leeds and Sussex. The NHS has not once voluntarily examined its own conduct. Nor have investigations been triggered by the CQC identifying problems.

Speaking with so many harmed parents over the past 12 months has filled me with immense sadness. I have walked away after interviews, sat in my car and cried. I feel rage, too. These families have been lied to, blamed for their own children’s deaths, denied answers to the most basic questions. Alongside their grief, they have had to become amateur detectives, forcing information into the public domain that hospital bosses would prefer remained hidden. They have acquired a level of medical knowledge that would put some clinicians to shame, just so they are able to challenge unreliable narratives. They should not have to fight so hard.

And they deserve so much more. Regulators, such as the General Medical Council and the Nursing and Midwifery Council, have never been held accountable for failing to step in and protect patients. Nor have NHS bosses, politicians, or the professional bodies that knew of concerns, and in some cases created the conditions for them to flourish.

Many families conclude that a statutory public inquiry, which can compel these organisations and individuals to provide testimony, is the only way forward. Even those who fear such an inquiry would delay urgently needed change are adamant that some kind of “broader process” is now needed. “Without this,” explains the patient safety campaigner James Titcombe, writing in the British Medical Journal, “we risk continuing to describe the symptoms while failing to diagnose the real problem.”

On one thing, Amos is most certainly right: “As a country, as a community, we cannot continue like this.”