Baroness Amos’ final report sets out recommendations for reform of maternity and neonatal care

Baroness Amos’ final report, published on 30 June 2026, marks a pivotal moment for maternity and neonatal care in England. It is both a stark indictment of systemic failings and a blueprint for long overdue reform.

The report’s findings, drawn from investigations across 12 NHS trusts, reveal patterns of harm, neglect, and cultural dysfunction that have persisted despite years of warnings. Its recommendations demand not only policy change but a profound cultural shift in how the health system listens, learns, and leads.

At the heart of the report is a simple but devastating truth: women and families were not listened to. Across every trust examined, women reported being dismissed, excluded from decision making, and left without answers when things went wrong. This failure to listen was the root cause of repeated harm, the erosion of trust, and preventable tragedy. It echoes what we hear when representing families who have been affected by poor maternity care.

The report also highlights chronic staffing shortages, burnout, and overwhelming demand. Staff described immense pressure, inconsistent communication, and environments where it was noted to the investigation that empathy was often ‘the first thing to go’. These conditions are not compatible with safe, compassionate care. They reflect a system stretched beyond capacity, unable to meet the increasingly complex needs of the women it serves.

Baroness Amos’ eight recommendations to address the systemic problems identified in the report are ambitious and structural, and timelines are proposed. They include establishing a statutory Maternity and Neonatal Commissioner, embedding anti-racist practice, strengthening accountability, designing a modern service framework, and investing in digital and physical infrastructure. These proposals are aimed at redesigning the system so that safety, listening, and learning become non-negotiable foundations rather than aspirational goals.

Crucially, the report centres the voices of families. Many shared traumatic experiences, reliving grief to ensure others would not suffer the same fate. Their testimonies reveal not only individual tragedies but systemic patterns: women turned away despite urgent symptoms, babies harmed because warning signs were missed, and families left without clear explanations. Trusts such as Oxford University Hospitals have already issued apologies, acknowledging the harm and committing to change.

Responding to this report will demand political will, sustained funding, and unwavering leadership. Baroness Amos’ report is a call to action: to listen, to reform, and to rebuild trust. The responsibility now lies with the NHS and government to demonstrate that meaningful change is both possible and underway.