Switalskis experts back call for maternity commissioner as Amos report demands urgent change in maternity services and says: ‘We cannot continue like this’

Expert medical negligence solicitors at Switalskis have backed calls for a national maternity commissioner to be appointed after the release of a report into maternity failings at 12 NHS Trusts as part of the National Maternity and Neonatal Investigation – the second damning report into maternity services in a week.

The support for a commissioner from Switalskis’ specialist maternity negligence experts comes as the report from the investigation, chaired by Baroness Amos, revealed a series of failings at the 12 Trusts examined.

The Amos report was released less than a week after a separate report was published by specialist midwife Donna Ockenden into failings at Nottingham University Hospitals NHS Trust after the largest inquiry into maternity services in NHS history.

It revealed more widespread issues across the 12 Trusts and maternity services in the NHS more generally, with Baroness Amos concluding that services were “no longer designed for the maternity and neonatal needs of today or the future”.

‘A system straining under pressure’: What the National Maternity and Neonatal Investigation Report said

In her report , Baroness Amos highlighted a number of key issues which were hampering the NHS’ ability to deliver safe and effective maternity services, leading to harm to women and babies.

Reflecting the experience of many women, babies and families, she said: “For too many (depending on where they live, who they are or simply the day they give birth), the care they receive is not good enough and can result in avoidable harm for women, birthing people and babies

“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.”

She also added that the current maternity system in the NHS was “a system straining under pressure, no longer designed for the maternity and neonatal needs of today or the future”.

The key issues the investigation identified were:

• Women, midwives and birthing people not being listened to, heard or believed
• Racism, discrimination and structural inequalities, which she said were “embedded throughout the maternity and neonatal system”
• Services not being designed in a way that ensures consistent safety
• A system which is fragmented and where care is “inconsistent”.

What are Baroness Amos’ recommendations?

In total, the National Maternity and Neonatal Investigation Report made eight recommendations, which are as follows:

1.       Creating a statutory national Maternity and Neonatal Commissioner to drive the urgent, systemwide change identified and to provide the oversight to drive accountability and implementation of a redesigned maternity and neonatal system. Baroness Amos also said that legislation for the Commissioner must be included in the Health Bill, which is currently in Parliament.

2.       Systematically listening to the voices of women, birthing people and families.

3.       Improving how the system responds and how it learns when something goes wrong.

4.       Creating a Modern Service Framework which sets out national standards to consistently achieve high-quality maternity and neonatal care.

5.       Tackling racism, discrimination and inequality.

6.       Improving system governance and accountability structures and regulatory oversight.

7.       Improving culture and teamworking, as well as strengthening leadership at all levels of the system and across professions.

8.       Delivering estates and digital systems that are fit for modern maternity and neonatal care.

‘Time for action’: our maternity negligence expert’s view

Suzanne Munroe is a Director and National Head of Medical Negligence for Switalskis. Our team is supporting dozens of families and children affected by negligence in maternity units included in the National Maternity and Neonatal Investigation, as well as those affected by failures at Nottingham University Hospitals NHS Trusts and Leeds Teaching Hospitals NHS Trust, which will itself be subject to an inquiry led by Donna Ockenden.

Commenting on the report by the investigation led by Baroness Amos, Suzanne said: “This is a troubling read for anyone connected with maternity services but will be especially difficult for those families who have suffered the loss of a baby or a life-changing injury to their child at one of the maternity units included in this review, as well as those affected by failures at Nottingham and Leeds.

“It is now clear that there are serious and widespread issues in maternity services across the NHS – not isolated failings at one or two Trusts, but concerns affecting maternity units in towns and cities across the country.

“We have seen the devastating impact of these failures in maternity care on the many families we have supported, families who have endured unimaginable suffering. While every instance of harm is one too many, the reality is that maternity services are currently strained beyond their ability to cope.

“NHS staff are working under immense pressure and do an extraordinary job in difficult circumstances. However, where staff are not listened to, feel unable to raise concerns, or are subjected to bullying cultures, safe care is put at risk. Right now, the focus must be on ensuring services are consistently safe for every family.

“Now is the time for urgent action. The Government must respond immediately to Baroness Amos’ findings and the recommendations of the Ockenden report. All families who have suffered harm or loss – and all those who remain at risk while these issues persist – deserve nothing less.”

“Wholesale change is needed, and we support Baroness Amos’ recommendation that a national maternity commissioner is appointed. It is no longer credible to suggest that the incidents affecting families and children are isolated. There are clearly systemic issues within NHS maternity services, and they must be addressed urgently.

"All too often, we see the heartbreaking consequences of the harm suffered by families. Every one of these incidents represented an opportunity for the NHS to learn and improve. The Amos and Ockenden reports demonstrate that too many of those opportunities have not been taken, resulting in others suffering unnecessarily."

What is the National Maternity and Neonatal Investigation

Our specialist medical negligence experts are supporting dozens of families who have experienced harm or bereavement in one of the 12 Trusts covered by the National Maternity and Neonatal Investigation.

The investigation was announced by the then Health Secretary, Wes Streeting, in June 2025. His decision follows meetings with a number of bereaved families and families of children who had suffered brain injuries or other life-changing birth injuries, including families who are being supported by Switalskis.

The Trusts are:

• Barking, Havering and Redbridge University Hospitals NHS Trust, which runs maternity services through Queen’s Hospital in Romford.
• Blackpool Teaching Hospitals NHS Foundation Trust, which operates the maternity unit at Blackpool Victoria Hospital
• Bradford Teaching Hospitals Foundation NHS Trust, which has a maternity unit at the Bradford Royal Infirmary
• East Kent Hospitals Foundation NHS Trust, which has two maternity units: the William Harvey Hospital in Ashford and the Queen Elizabeth the Queen Mother Hospital in Margate
• Gloucestershire Hospitals Foundation NHS Trust, which operates maternity services from the Gloucestershire Royal Hospital
• Oxford University Hospital NHS Foundation Trust, which has a maternity unit at the John Radcliffe Hospital as well as other centres including the Oxford Spires Midwifery-led Unit, Cotswold Birth Centre, Horton Midwifery-led Unit, Wallingford Maternity and Birthing Centre and the Wantage Maternity Unit
• Sandwell and West Birmingham Hospitals NHS Trust, which has a maternity unit at the Midland Metropolitan University Hospital
• The Queen Elizabeth Hospital, King’s Lynn NHS Foundation Trust
• University Hospitals of Leicester NHS Trust, which has three units at Leicester Royal Infirmary, Leicester General Hospital and St Mary’s Hospital in Melton Mowbray
• University Hospitals of Morecambe Bay NHS Foundation Trust, where maternity services operate from three sites: the Royal Lancaster Infirmary, the South Lakes Birth Centre at Furness General Hospital and Helme Chase at Westmorland General Hospital
• University Hospitals Sussex NHS Foundation Trust, which has consultant obstetric-led units at the Royal Sussex County Hospital in Brighton, the Princess Royal Hospital in Haywards Heath, Worthing Hospital and St Richard’s Hospital in Chichester, as well as midwife-led units in Chichester, Eastbourne and Crowborough. 

Chaired by Baroness Amos, the investigation was set up in response to systemic issues in maternity and neonatal care going back for several years and followed a series of independent reviews into NHS maternity care.

Specialist maternity solicitors supporting families – how we can help

Our specialist birth injury solicitors are supporting many families who have been harmed or suffered the loss of a baby at the maternity units operated by the 12 Trusts examined under the National Maternity and Neonatal Investigation. We are also representing families who suffered harm or bereavement while under the care of Nottingham University Hospitals NHS Trust, which operates maternity units at Queens Medical Centre and the City Hospital, and the Leeds Teaching Hospitals NHS Trust, which has two maternity units: Leeds General Infirmary and St James’s University Hospital.

Finding out what went wrong with their birth, obtaining answers and ensuring lessons are learned are all important steps for families affected by poor care, whether that is at the 12 Trusts covered by the Amos Review or other Trusts around the country where are we supporting families.

Our specialist medical negligence solicitors have extensive experience in supporting families with highly complex maternity claims and investigations while offering the compassion, sensitivity and expertise you and your family rightfully expect.

We are also instructed regularly in cases where families have been told that no further action is possible. A careful review of the evidence and identifying opportunities others may have overlooked often enables our experts to restore a sense of direction and possibility for families who often feel they have exhausted all of their options.

For compassionate advice from our experienced medical negligence team , contact us today. Call 0808 303 0044  or email help@switalskis.com  .