The government has announced plans to appoint a national maternity commissioner, following a damning report that exposed repeated failures in NHS care, leaving families to suffer.
The “rapid review”, spearheaded by Baroness Valerie Amos, calls for urgent reforms to how women and their families are treated, particularly concerning their interactions with healthcare providers during pregnancy and labour.
Lady Amos stressed the necessity for families to have the right to an independent investigation into their care when adverse events occur and they dispute the findings of internal NHS reviews.
She also highlighted the critical need to improve hospital culture and foster better teamworking among midwives, obstetricians and other medical staff. Furthermore, the report suggests a comprehensive overhaul of rotas to ensure obstetric consultants and anaesthetists are consistently available on delivery units, facilitating “timely critical senior decision making and intervention 24 hours a day, seven days a week”.
While “the vast majority of pregnancies and births in England have a positive outcome and we have seen many examples of good practice”, Lady Amos pointed to poor care embedded across the system.
Health secretary James Murray said he was “not taking anything off the table” when asked if a full public inquiry should take place.
“I can understand where that feeling comes from. A very strong desire for real accountability for people who have been involved in some of these failings in maternity services, or involved in covering things up when they’ve gone wrong,” he told BBC Breakfast.
He also highlighted a “culture of cover up” in NHS maternity care and asked by Sky News if there was a misogynistic culture he said: “I think a lot of it is.
“I think it’s also a culture of cover-up, senior leaders, where they’re more interested in covering up failings rather than putting patients first.”
The government responded by agreeing to Lady Amos’ key request – for a national commissioner to provide independent leadership to hold the system to account. The Department of Health will also publish a national action plan on maternity in December.
The Maternity Safety Alliance, which includes bereaved families, said there is still a need for a statutory public inquiry and the recommendation for a maternity commissioner is “fundamentally dangerous”, with that person not being “meaningfully independent”.
Among the concerns Lady Amos’ team found were:
– “Women and birthing people not being listened to, heard or believed”, with “serious consequences for the safety and quality of care they receive, resulting in avoidable harm, trauma and loss of confidence in themselves and in the system.”
– Racism, discrimination and structural inequalities “embedded throughout the maternity and neonatal system, with profound implications for outcomes and the quality of care women and babies receive”.
– “Services not designed in a way that ensures consistent safety.” Antenatal care does not fit required needs.
– The system “is fragmented and care is inconsistent”, including mental health services, antenatal care, labour and birth not being “joined up”.
– The impact of “medical misogyny” was found throughout, “leading to an embedded culture in which women’s voices are ignored”.
– “Women, birthing people and families told us about not being listened to, heard or believed, meaning they had been dismissed when raising concerns, leading in some cases to avoidable harm or unsafe care.” People told how they were not treated with kindness or compassion.
– Some patients told how they had “not been able to give informed consent to medical procedures, due to poor communication and lack of information.”
– Others “suffered pain and distress during a Caesarean section or assisted vaginal birth due to inadequate anaesthetic block”.
– Patients also told of racism and discrimination, including “receiving unfair or unequal treatment, leading to delays, unsafe care with, at times, devastating outcomes.” Some told of stereotyping and racial slurs on NHS wards, Islamophobia and antisemitism. One Muslim patient was asked “why are you wearing this?” while a Jewish patient was told “Jewish people are sneaky”.
– Staff told of being “ignored and dismissed” when they raised concerns about whether they could provide safe care or if they flagged excessive workloads.
– Staff also experienced racism, “both from other staff and from women, birthing people and families”.
– They told of working in poor-quality and sometimes dangerous clinical environments,” often working long shifts without breaks, in areas lacking appropriate spaces” for rest.
– Workers told of “a lack of visible leadership”, insufficient training and “poor working culture”. There were reports of “challenging cultures, with fear, staff feeling blamed, hierarchical structures, inequity in leadership structures, racism and discrimination…”
– The review found that while women’s autonomy should be respected, “birthing outside of clinical guidance – whether by declining recommended interventions, not coming into hospital when advised to, or giving birth without any assistance from maternity staff (freebirth) – is a growing challenge for NHS maternity.”
Overall, the report found services were not designed to ensure consistent safety, resulting in “avoidable harm and lifelong trauma” and a “lack of accountability from trusts when things had gone wrong”.
Families who tried to get answers when harm occurred felt that internal investigation teams were “marking their own homework” and “investigations contradicting the original account of what had happened and/or downplaying or reframing failings”. NHS trust leadership was also reported as prioritising protecting their reputation over learning from mistakes.
Patients reported being told it was “just one of those things” when things went wrong, even though they knew harm had been caused.
“Women and families told us of cases where harm had occurred and no investigation or review was undertaken because staff judged there to be no errors in the care provided.”
The Amos review gathered the views of more than 450 families and received over 10,500 responses to a public call for evidence.
Some 12 NHS trusts with poor records on maternity were visited and more than 9,000 staff contributed.
National leaders and other senior people described to assessors a maternity and neonatal system in which there is “fragmented governance, with too many organisations, an abundance of overlapping recommendations to be implemented, an overwhelming amount of guidance, unclear lines of responsibility and inadequate regulatory oversight for ensuring safety and change.”
They also said there were also “persistent workforce pressures, with shortages, attrition, rota gaps” and high staff absence rates.
The report further found care was being given “in poorly maintained and, at times, unsafe clinical environments”.
The report comes less than a week after an inquiry into Nottingham University Hospitals NHS Trust (NUH), led by senior midwife Donna Ockenden, found more than 500 mothers and babies suffered avoidable harm or died due to “deeply embedded systemic failures” at the “toxic” hospital trust.
NUH knew there were serious issues in its maternity department going back years, but failed to take action to prevent more deaths.
Lady Amos described hearing “heartbreaking cases” and said the “emotional toll and cost to families is indescribable”.
She added: “Women, babies and families deserve maternity and neonatal care that is safe, compassionate and equitable wherever they live.
“Too often, this investigation heard that people were not listened to, that harm was repeated, and that families were left without clear answers or accountability when things went wrong.
“This report sets out practical action to change that.”
On her recommendations, Lady Amos said the new maternity commissioner must be accountable to Parliament and have a “relentless focus on improving maternity and neonatal care”, with the aim of redesigning the service.
This includes “clear minimum national standards for safety and putting in place effective governance and accountability.”
The report said NHS trust boards must have clear oversight of how patients are triaged for care, including regular reviews of waiting times and performance.
Within a year, there should also be a national standard brought in for what good triage looks like, and all maternity units must also have dedicated triage staff, who are all trained in rapid assessment.
Lady Amos said if the triage of women was improved, “lives will be saved and harm reduced.”
The report also said that when death or harm occurs, “families should be offered a full explanation of what happened”.
It added: “There is an imbalance of power between trusts and families and the resources available to them, which can prevent families from receiving the answers they deserve when things go wrong.”
The report further said the Government and regulators such as the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) must “treat racism, discrimination and inequality as a critical maternity safety issue”.
She called for immediate steps to “improve the regulatory oversight” of maternity provided by hospital regulator, the Care Quality Commission (CQC) and closer working among all bodies to clarify responsibilities, remove duplication and improve effectiveness.
In addition, developing a positive culture in NHS trusts “which prevents and tackles poor and unacceptable behaviour should be treated as a critical safety issue.” The voices of families must also be treated as a critical safety issue, with data captured.
Further actions include guidance for situations where women decline recommended clinical care, a move away from “a fixed risk categorisation” of pregnancies as “high risk” or “low risk”, with this looked at at every appointment, and every family to get a “debrief discussion” after birth.
Health Secretary, James Murray, said: “For too long, women, babies and families have been failed by a system that didn’t listen. Their stories are heartbreaking and demand action.
“Appointing the UK’s first ever maternity and neonatal commissioner will drive lasting change and make sure women and families are never ignored again”.
The Government also committed to rolling out a national perinatal equity and anti-discrimination programme.
Some 1,000 temporary roles will also be created to help newly-qualified midwives join the NHS, backed by more than £10 million in funding.
The Birth Trauma Association said the Amos review was “disappointing for families” and a “huge missed opportunity”.
