“We Can’t Continue Like This”: The National Maternity And Neonatal Investigation Findings Show A System That Is Failing

The publication of Baroness Valerie Amos’ national inquiry into NHS maternity services marks a stark and deeply concerning moment for maternity care in England. For families, clinicians, and legal professionals alike, the findings are not only troubling, but they are also, quite simply, unacceptable.

You can read the full report here.

In this blog, we reflect on the National Maternity and Neonatal Investigation’s findings and the deeply concerning conclusions reached by Baroness Valerie Amos about the state of maternity care in England. The report paints a stark picture of a system that is failing too many women and babies, highlighting serious, systemic shortcomings that have, in some cases, led to avoidable harm.

Its findings underline the urgent need for meaningful reform. As the report itself makes clear, “we cannot continue like this” — and for families affected by poor care, that reality has been all too apparent for some time.

For those who have suffered harm during pregnancy, labour, or postnatal care, this report may resonate all too strongly. It shines a light on systemic failings that many families have been raising for years, and it reinforces a sobering reality that much more must be done to ensure safe, compassionate, and equitable maternity care in the UK.

A system “not set up” to deliver safe care

At the heart of the Amos Inquiry is a damning conclusion: the NHS maternity system in England is not currently structured to consistently deliver safe, high-quality and compassionate care.

The report describes a system that is:

Perhaps most concerning is the finding that there is a fundamental failure to listen to women and families. This is not simply a matter of poor communication; it is identified as a critical patient safety issue, contributing directly to avoidable harm.

For many families who have experienced traumatic births or loss, this will feel like long-overdue recognition.

Unacceptable” racism and discrimination

One of the most serious aspects of the inquiry is its conclusion that racism and discrimination are embedded within maternity services.

This is a deeply troubling finding. It highlights that disparities in outcomes, particularly for women from Black, Asian, and minority ethnic backgrounds, are not incidental but systemic.

The report calls for:

These are not minor adjustments. They require a fundamental cultural shift across the healthcare system.

A series of scandals — not isolated incidents

The Amos Inquiry does not exist in isolation. It follows a series of high-profile maternity scandals across the UK, including investigations into services in:

These cases have revealed repeated patterns of:

The fact that similar failings are being identified across multiple trusts underscores a critical point: these are not isolated failings, but systemic ones.

Urgent changes are needed

Baroness Amos has set out eight key recommendations aimed at overhauling maternity care.

Among the most significant are:

The report makes clear that improving triage alone could save lives and reduce harm.

Yet, there remains concern among families and campaigners that previous recommendations from earlier inquiries have not been fully implemented, or have been diluted over time.

Disagreement and criticism

Despite the strength of its findings, the report has not been without controversy.

Some experts have publicly disagreed with aspects of the conclusions, particularly around whether there has been a widespread culture of promoting “normal birth” at the expense of patient choice, including access to caesarean sections.

Meanwhile, campaign groups and bereaved families have raised concerns that the report does not go far enough in reflecting lived experiences, that some critical issues, such as birth trauma and certain types of injury, are underrepresented, and that proposed reforms may lack sufficient independence or accountability

This divergence of views only reinforces the urgency of meaningful reform, reform that must be robust, transparent, and genuinely patient-focused.

“We cannot continue like this”

Perhaps the most powerful statement from Baroness Amos is also the simplest: “As a country… we cannot continue like this.”

For those working in clinical negligence, this statement is more than rhetoric — it is a recognition of the human cost behind systemic failure.

Every statistic represents a family coping with life-changing injury, parents grieving the loss of a child, or individuals navigating trauma that could and should have been avoided

Moving forward

While the government has pledged funding and a future action plan, real change will depend on:

The findings of the Amos Inquiry should serve as a catalyst for transformation. Anything less risks repeating the same tragic outcomes that have already affected so many.

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If you or a loved one has experienced complications during pregnancy or childbirth and is concerned about the care provided, seeking legal advice can help you understand your position.

Our specialist clinical negligence team has extensive experience in maternity cases and is committed to supporting families with sensitivity and expertise.