An independent inquiry into England's maternity services has identified significant failings, including "unacceptable racism and discrimination" that compromise patient safety. The National Maternity and Neonatal Investigation, established last summer by the then-health secretary Wes Streeting, aims to drive improvements across the National Health Service (NHS) following a series of maternity scandals.
Baroness Amos and her team gathered insights from over 450 families and visited 12 NHS trusts to pinpoint necessary changes. The investigation's report concludes that a key systemic failure is an unwillingness to listen to women and their families, which has led to poor outcomes. It also found a lack of consistent care standards, with considerable variation across the health service.
"The system is fragmented, overly complex and too slow to learn and improve," Baroness Amos stated in her report. One of the immediate recommendations is to overhaul maternity triage services, which she described as increasingly functioning as the emergency department for maternity care. The report urges that midwives be dedicated to handling calls and providing timely advice, with women offered face-to-face appointments if they remain concerned. Implementing these changes, the report suggests, could "save lives and reduce harm."
Furthermore, the inquiry found that racism and discrimination must be treated as critical safety issues requiring urgent intervention. This includes collecting detailed data on unequal outcomes, which should be escalated to board level when patterns emerge.
While acknowledging calls for a statutory public inquiry that could compel testimony from senior figures at under-fire hospital trusts, Baroness Amos expressed reservations. She told the BBC that statutory public inquiries are very lengthy and, based on her investigation's work and conversations with families, she does not currently see a need for one, though the final decision rests with others.