Systemic Failures, Silenced Families, and Unsupported Staff: Our Response to the Amos Interim Report

The Amos Interim Report: What It Reveals and What Must Change Now

The interim report from the National Maternity and Neonatal Investigation, led by Baroness Valerie Amos, has now been released and its early findings paint a stark, deeply concerning picture of maternity and neonatal care across England.

After hearing from more than 170 families and visiting multiple NHS Trusts, Baroness Amos states that what she has seen so far is “far worse” than she anticipated. While many families shared experiences of compassionate, personalised care, the investigation has also uncovered widespread, repeated patterns of unsafe practice, poor communication, missed warning signs, and discriminatory experiences, issues that have remained unresolved despite almost a decade of maternity inquiries and 748 existing recommendations.

For families, and for the professionals dedicated to caring for them, this moment represents both a painful reckoning and a critical opportunity for meaningful change.

As a charity committed to preventing baby loss and improving maternity safety, MAMA Academy welcomes this interim report and remains determined to ensure its findings lead to urgent, sustained action.

 

A Decade of Warnings and Still the Harm Continues

Since 2015, England has seen multiple major maternity investigations including: Morecambe Bay, Shrewsbury and Telford, and East Kent. Each exposing serious and preventable harm. Many believed these reviews would mark a turning point.

Yet the Amos investigation asks an essential question:

Why, after so many reports and recommendations, are we still failing to provide safe and consistent maternity care?

The interim findings suggest the causes are not isolated. They are systemic, longstanding, and occurring across many different types of Trusts and communities.

Across every Trust visited so far, families described similar experiences: not being heard, not being supported, and not being kept safe.

 

Baroness Amos reports highly consistent themes:

1. Women not being listened to

Concerns, including reduced fetal movement, were often dismissed or not acted on, even when women clearly communicated that “something isn’t right”.

2. Poor communication at critical moments

Many families said they were not given clear information, risks were not explained, and choices were limited or misunderstood.

3. Discriminatory experiences

Black and Asian women, working-class women, younger parents, and women with mental health needs frequently described poorer care and feeling judged or unsafe.

4. Basic standards of care not met

The investigation heard repeated accounts of unclean wards, missed meals, catheters not checked or emptied, and women not helped to use the bathroom.

5. Birth plans ignored

Families described plans not being read, not being followed, or needing to repeat their wishes repeatedly during labour.

6. Families feeling blamed or dismissed

Some bereaved parents were left feeling responsible for what happened, or received no apology when care fell short.

7. Distressing environments after loss

Several parents were placed on wards alongside newborns after experiencing the death of a baby, an avoidable and deeply painful oversight.

8. Delays in accessing information

Long waits for autopsy reports and difficulty accessing medical notes left families unable to understand what happened, sometimes for months or years.

9. Fragmented care after harm

Families reported dealing with multiple services that did not communicate effectively, prolonging trauma and delaying support.

While these themes are devastating, they are also invaluable. They offer a clear, collective voice expressing what must change.

 

What the Report Reveals About Staff Experience

Importantly, the interim report emphasises that these failings are not the fault of individual midwives and clinicians.

Many professionals described:

Unsafe workloads

Being routinely short-staffed, pulled away from core duties, and unable to provide the standard of care they were trained to deliver.

Emotional and moral injury

Staff spoke of the deep distress caused when systemic pressures prevent them from giving safe, compassionate care, an experience mirrored in international research on moral injury within healthcare.

Hostile behaviour from the public

Some midwives reported rotten fruit thrown at them, abuse online, and even death threats following negative media coverage.

Broken infrastructure

Obsolete IT systems, poor estates, lack of equipment, and overwhelming reporting requirements took time away from patient care.

Positive improvements where leadership is strong

Staff also described meaningful gains where senior midwives were visible, specialist roles were supported, and leaders prioritised communication and culture.

The consistent message is clear:
Midwives and doctors want to provide safe care, but a broken system makes that impossible.

 

Why This Review Is Supposedly Different

Some families remain sceptical and believe only a statutory inquiry will deliver justice. Others welcome the investigation’s focus on systemic solutions rather than individual blame.

Key differences in the Amos investigation include:

• Families consulted on the Terms of Reference

Their feedback has shaped the process from the beginning.

• “Families first” engagement before each Trust visit

Ensuring real experiences guide on-site investigation.

• A Call for Evidence from all affected families (launching January 2026)

This gives parents across England a direct voice.

• Insight from international experts

To identify best practice that could be embedded in England.

• A single set of national recommendations

Designed to be actionable, measurable, and accountable,  something missing in many past reviews.

 

What Happens Next

January 2026

Launch of the national Call for Evidence for families and staff.

February 2026

Publication of initial findings following the site visits.

Spring 2026

Final report and national recommendations.

These recommendations will then be taken forward by the National Maternity and Neonatal Taskforce, chaired by the Secretary of State.

 

At MAMA Academy,we believe:

Parents must be listened to.

No concern should be dismissed. No warning sign ignored.

Evidence-based surveillance is essential.

National standards for fetal growth and fetal wellbeing must be monitored, audited, and transparent.

Inequalities must be confronted head-on.

Discriminatory care contributes directly to preventable harm.

Midwives and doctors must be supported, not blamed.

Safe staffing, functioning systems, and compassionate leadership are non-negotiable for safe care.

Accountability must be real.

Recommendations must be implemented, measured, and sustained, not repeatedly rediscovered after preventable deaths.

We are committed to ensuring families’ voices remain central to the conversation, and to supporting professionals who deliver compassionate care under immense pressure.

The Amos interim report is a wake-up call  but it also marks a rare opportunity:
The chance to finally deliver safe, consistent maternity and neonatal care across England.

Families deserve it.
Midwives deserve it.
Babies deserve it.

And the time for change is now.