Women and NHS bosses cannot rely on official ratings to determine the safety of maternity units, Members of Parliament were warned. Baroness Valerie Amos, who led a national maternity review, stated that the Care Quality Commission (CQC) is unable to provide consistently dependable assessments.
During her review, Amos discovered that one hospital trust, despite having seven significant safety failures identified by inspectors—including instances of women leaving maternity triage without being assessed—was still rated as 'good.' This raises concerns that pregnant women may enter maternity services unaware of pre-existing serious dangers.
Donna Ockenden, another maternity investigator, echoed these concerns, telling the Commons Health and Social Care Committee that healthcare regulators are in their 'last chance saloon.' She indicated that warnings had been ignored and opportunities to intervene had been missed over many years.
Baroness Amos, whose National Maternity and Neonatal Investigation was published recently, informed the committee that the CQC cannot consistently assure safety. She explained that the consequences of unreliable ratings extend beyond public perception, as NHS trust boards use the regulator's findings to prioritize urgent actions. "If you can't trust the regulator and can't trust what the regulator is telling you, then you are not going to end up with a service that has better quality and is safer for women and families," Amos warned.
Her national review identified significant inconsistencies in how CQC inspectors operate, a lack of clear standards, and insufficient specialized expertise. Amos noted that some trusts reported their assessment criteria changed even while they were under investigation. She confirmed that the move towards more generalist inspections had contributed to these failures.
Amos's investigation concluded that maternity and neonatal services should be evaluated by specialists with a deep understanding of the unique pressures, risks, and warning signs within these units. This, she argued, would enable a more accurate recognition of when services are failing.
Ockenden, whose recent probe into Nottingham University Hospitals NHS Trust found over 500 mothers and babies suffered avoidable harm or died due to systemic failures, offered a critical assessment of the broader regulatory system. She stated that coroners had repeatedly identified negligence, but regulators had failed to grasp the scale of the problems.
While acknowledging improvements in the relationships between regulators like the General Medical Council, Nursing and Midwifery Council, and CQC with families, Ockenden emphasized this progress was achieved only after sustained pressure. "That has been hard won. That has been hard work," she said, adding, "I think we are on last chance saloon."
The government has committed to a maternity action plan within six months, in response to the Amos review. However, Ockenden urged for a more immediate response, warning that further harm could occur while ministers deliberate. She stressed that the health service already possesses knowledge of necessary changes from years of scandals and ignored recommendations. "I would say we don't have six months to create an action plan," Ockenden stated.
Amos reinforced this urgency, highlighting the risk of insufficient monitoring and delays in addressing issues. She appealed to the government to implement her recommendations comprehensively, cautioning against a selective approach. "Please don't do pick and mix here," she pleaded.
MP Alex McIntyre shared constituent experiences, including a woman experiencing continued pain after a spinal block who was dismissed by a consultant, and another told 'it's just one of those things' after her son's death following a premature birth. Another case involved a mother whose baby was in neonatal intensive care but who was placed on a ward with other newborns and advised to buy earplugs due to distress.
Amos's review also found evidence of 'medical misogyny' within the system. She stressed that racism, discrimination, and a failure to listen to women should be treated as immediate patient safety threats, rather than lesser cultural issues. "How, in today's world and looking forward, we still have the scale of harm and bereavement that we do. I find extremely difficult to get my head around," she added.