The UK government has pledged to appoint a statutory maternity commissioner to oversee reforms following a national investigation into repeated failures in NHS maternity care. The move responds to findings from a report led by Baroness Amos, a Labour peer who chaired the National Maternity and Neonatal Investigation, commissioned by then-Health Secretary Wes Streeting in August 2025.

The investigation, which reviewed 10,000 pieces of evidence spanning 12 NHS trusts and included interviews with 450 families and 38 hospital executives, was published in late June 2026. It highlights systemic issues contributing to avoidable harm and deaths among mothers and babies, most notably in Nottingham, where more than 500 such cases have been documented in what is considered the largest maternity scandal in NHS history.

A central concern identified by Amos is the failure of hospitals to ensure that senior medical staff are present on maternity wards during nights and weekends. The report calls for a restructuring of NHS rotas to guarantee that obstetric consultants and anaesthetists are available 24/7 to provide timely critical decision-making and interventions.

The investigation also recommends overhauling triage procedures to better detect early warning signs of complications, asserting that improved systems could save lives and reduce harm. Additionally, Amos’s report condemns an entrenched culture of “medical misogyny” within maternity services, where women’s concerns are frequently dismissed or trivialized. Examples include women being denied pain relief or labeled as “wimps,” representing wider concerns about how patient voices are treated.

Contrary to earlier maternity inquiries, the report finds that “normal birth” ideology—the preference for births without medical intervention—is not a widespread influence within current maternity practice. This conclusion has been contentious, contributing to the resignation of one of Amos’s advisers, Bill Kirkup, who previously led reviews into other maternity scandals and had highlighted this ideology as a factor in avoidable deaths.

The report also documents instances of racism in maternity care, noting that Asian women were stereotyped as “princesses” while Black women were told they could endure pain more readily, reflecting broader systemic biases in treatment.

In response to the findings, the government agreed to establish the maternity commissioner role with statutory powers to drive improvements and hold healthcare providers accountable. Officials also announced plans to publish a comprehensive national action plan by December 2026 aimed at delivering long-term reform. Additional measures include ending the practice of hospital trusts self-investigating maternity failures, instead mandating independent review at each stage to foster a culture focused on learning rather than blame.

Baroness Amos’s report criticizes the Care Quality Commission (CQC) for a “severe disconnect” between hospital ratings and the realities experienced by patients, stating the regulator lacks the specialized expertise required for accurate assessments of maternity and neonatal services.

The report arrives amid rising financial and emotional costs associated with maternity negligence claims, with the NHS paying £1.6 billion in such cases last year. Families involved in these incidents often face protracted and adversarial legal processes, which the report suggests should be reconsidered to reduce their trauma.

Among those affected is Katie Fowler, whose daughter Abigail died shortly after birth at University Hospitals Sussex in 2021 following alleged failures to escalate care. Fowler criticized the report for not recommending a statutory public inquiry, which she and others argue is necessary to compel comprehensive scrutiny of NHS trusts, leadership, and regulatory bodies. Similar concerns were voiced by Chelsea Gowar, who lost her daughter Bonnie in 2025, describing the burden of campaigning for accountability as an ongoing struggle for bereaved families.

Baroness Amos’s report marks a significant intervention in efforts to address ongoing crises in NHS maternity care, signaling government intent to implement systemic reforms while highlighting the continuing calls for greater transparency and accountability from affected families and advocacy groups.