Commitments to root and branch change in maternity

Written by Anna Davies, Joanna Lloud, and Kate Jury.

Introduction

Our Partners, Anna Davies and Joanna Lloyd have come together with Kate Jury, Managing Partner of Niche Health and Social Care Consulting to consider the key developments in maternity services following the delivery of the recent reviews conducted by Donna Ockenden and Baroness Amos. 

Two major maternity reviews have once again placed the safety, culture and accountability of maternity and neonatal services under national scrutiny. 

The Ockenden review into maternity services at Nottingham University Hospitals NHS Trust and Baroness Valerie Amos’s National Maternity and Neonatal Investigation both describe systems in which too many women, babies and families were not listened to, warning signs were missed, and opportunities to prevent harm were lost.

While the Nottingham review has focussed upon the problems of ‘what happened and when’, the national review focuses more upon the ‘why and what’ to improve at a systemic level. Both reports are important in different ways and offer, between them, helpful synergies. Combining the testimonies of families and staff, academics and senior leaders, all underpin the definitive evidence-base needed to commit to root and branch change.

What the Nottingham review found

The report on Nottingham University Hospitals NHS Trust reviewed more than 2,500 family cases and considered the quality of care relating to newborn, infant and maternal harm. Ockenden has continued to raise the voices of women and families and has ensured an unrelenting focus upon maternity harms.

One recommendation of significant importance within this review is the ability for women and families to seek a second opinion via Martha’s Rule; this is a major expansion. But as one family member in the subsequent Amos review states ‘What good is a second opinion if it takes you five and a half hours to get the first? 

“Martha’s Rule and a normalised culture of second opinions will take a long time to evolve into the DNA of the NHS”

The availability of second opinions has always been a grey area in the NHS for several reasons (practicality, scale, record sharing protocols, defensiveness, fear of litigation amongst them). Yet Germany has some of the lowest neonatal and maternal mortality rates in the world, and a second opinion is part of normal business; it is a legal right and must be facilitated by doctors and midwives who are completely culturally accustomed to this non-defensive way of working. 

Martha’s Rule and a normalised culture of second opinions will take a long time to evolve into the DNA of the NHS, but it is a necessary expansion for safety, particularly in maternity triage and labour wards. 

What the national review tells us

Baroness Amos’s National Maternity and Neonatal Investigation looked more broadly across maternity and neonatal services in England, and included evidence from families, staff, national leaders and primary insights spanning across 12 NHS trusts. The central message is that the current ‘system’ is not designed or empowered to deliver safe, compassionate and equitable care. 

“Helping staff to tackle poor behaviours at source, exhibiting role model behaviours, and giving them the tools and equipment they need to deliver great care, should be a priority action”.

The report also carefully acknowledges that there is a need to work with maternity staff to support them to deliver the care they want to be able to provide. This has been a sector under pressure for a long time and almost everyone acknowledges that more maternity reviews are not needed, but direction, action and the increased resourcing of front-line services is. The new maternity commissioner should prioritise the important task of making sure that women continue to be heard and to get resolution and understanding where this has still not been achieved.

For staff, feeling valued, part of the solution, able to have pride in their profession, is so important for patient safety and their own psychological safety. It is stark that many staff are aware of the incivility and tension exhibited by a (small) number of their peers but that they don’t quite know how to address this. Helping staff to tackle poor behaviours at source, exhibiting role model behaviours, and giving them the tools and equipment they need to deliver great care, should be a priority action for all units.

Digital disadvantage and digital harm…

The Health Services Safety Investigations Body (HSSIB) review in 2025 found that Electronic Patient Record (EPR) systems could contribute safety critical risks to patients including missing, delayed or incorrect care. Particularly, poor procurement and variable implementation of an EPR can mean that this systemic dysfunction, has become ‘hard baked’ into front-line delivery. 

“Lost appointments, missing records, having to repeat histories, a lack of a reliable understanding of the facts when a harm occurs are all unnecessary - but all too familiar - markers of experience, which need to be tackled through proper digital transformation”.

Despite the HSSIB recommendations at the time, the Amos report, found a continued prevalence of many of the same issues. The need for resilient and future-fit digital systems to meet the needs of modern maternity and neonatal care is now mission critical. ‘Ambient AI’ for note taking, ‘bedside digital notes’ are all now easily within reach of our services.

Yet maternity Healthcare workers still describe a daily landscape of competing pressures where (sometimes repetitive and onerous) administrative tasks routinely collide with clinical delivery. Instead of acting as an accelerator for patient safety, technology has frequently become an impediment to progress. Take for example:

• Crucial details regarding medication or emergency vulnerability exist on one platform but remain invisible on another.
• In fast-moving medical emergencies, slow or freezing digital interfaces cannot keep pace, in some cases resulting in staff recording vitals on paper.
• Over half of all maternity and neonatal departments still rely on a hybridised system of paper charts and digital which vastly increases the risk of human error.
• Where systems don't connect, referrals can go unactioned and patients are left to chase their own care, sometimes only discovering gaps once an intervention has already been delayed.

Ultimately of course, a poor digital landscape can have a direct impact upon the trust that women and families feel in their maternity services. Lost appointments, missing records, having to repeat histories, a lack of a reliable understanding of the facts when a harm occurs are all unnecessary -but all too familiar- markers of experience, which need to be tackled through proper digital transformation.

Better demographic data will unlock change

Given that the national review was focussed upon systems across 12 trusts, it is not surprising to see the focus upon the increasing complexity of maternal care. Inherent population health risks are increasing and at a Neighbourhood Health level there needs to be a renewed focus on pre-conception care in all populations.

“What works in Surrey, might not work in Hull, Greater Manchester or Cumbria”. 

How an organisation understands its local demographic, in all forms, can be the difference between providing safe care and just being able to deliver a fragile service. What works in Surrey, might not work in Hull, Greater Manchester or Cumbria. 

Predicting and understanding population data can support many aspects of maternal safety including:

• Demand and capacity management influencing bed availability, shift management and an effective triage process. 
• The way staff are able to target care towards inherent population risk such as obesity, smoking, diet, exercise, age and culture. Particularly, compounding or intersectional risks; we are so used to assessing risks along individual parameters. 
• The training needs to ensure cultural (and religious) competence in staff. In some localities, ‘ethnic minority populations’ are in the ‘global majority’; are we learning from localities which have adapted, changed and increased their understanding of cultures, religions and the discrimination which is often indirect rather than overt.
• The increasing complexity around mental health presentations in women, trauma, neurodiversity and in some cases, the fear of pregnancy and childbirth in itself, are all increasing the burden on maternity services to deliver far more individualised and informed care without the corresponding uptick in training or resource.

When things go wrong… 

As was acknowledged by Mrs Justice Cox in Smithers v Taunton and Somerset NHS Trust [2004] EWHC 1179 (QB) there are inherent risks in pregnancy and childbirth that even with optimal care sometimes cannot be avoided. Babies can tragically suffer neurological injury, be miscarried, stillborn, or suffer from SIDS. Women and families can be left with lasting physical or psychological trauma. 

The process of birth itself can change on a minute-by-minute basis, and any delays can be critical to the outcome; there are no absolute guarantees.  Within an optimised safety culture, with enough staff, where women are listened to, the space between an ‘expected’ and ‘unexpected’ outcome will reduce.  

In future years families should not need to go through the devastation of trying to find answers or being told their experiences do not mirror reality. Changes to the way hospitals investigate incidents when harm is thought to be linked to failures in care, via the Patient Safety Incident Response Framework (PSIRF), should put families at the heart of the investigation. 

Likewise, the Early Notification Scheme (ENS) introduced by NHS Resolution has improved the very long lag times between an incident and the resolution of an ensuing claim. But there is more to be done. Families should have access to a truly independent investigation which avoids bias, and where all parties, including legal teams, can trust in a prompt and reliable account. Families need to be treated with parity, kindness and respect and believed as the experts in their own experience. 

Improved access to Legal Aid for representation in inquiries and inquests envisaged in the Public Office (Accountability) Bill 2025, colloquially known as Hillsborough Law, will help level the playing field. 

Ensuring a democratic understanding of the future state of maternity services

A multi-dimensional view of the whole landscape of maternity has now been delivered through these and other reports. All have used different and useful methods to shed light on shared experience, generating evidence which leads to discourse, a scientific understanding, new public policies and new multi-disciplinary best practice guidance.  No voices should be exempt from that process, even when they don’t agree; because ultimately, pregnancy and childbirth will feature in the lives of most people, in some way and at some stage. Maternal safety is in the interests of all.

What a fitting tribute it would be to the late Professor Tim Draycott, if the right way really did become the easy way.

One final thought: In England, we are so good at saying what is wrong with the NHS. The tens of thousands of positive births that occur each year have become a byline. Some of our maternity services are outstanding, and some of our European neighbours have some of the best outcomes in the world. Collaboration rather than division is vital so we can learn from the best and when we meaningfully start look at success rather than just failure we can construct a new paradigm around maternity services. 

What a fitting tribute it would be to the late Professor Tim Draycott, if the right way really did become the easy way.

How can we help?

Amos’s findings echo what we’re already seeing in our own work advising NHS providers of maternity services. Our health team advises NHS organisations on the procurement, contracting and governance issues that underpin digital transformation in Health and Care settings. If you're starting to think through what the Amos recommendations mean for your organisation, our specialist team including Anna Davies and Joanna Lloyd would be glad to discuss how we can help. 

If you are interested in gaining independent assurance around your maternity services, particularly if you have already implemented review recommendations or have embarked upon a programme approach, Niche has a dedicated maternity assurance tool to help you quickly identify residual gaps in your maternity improvement plan. Please don’t hesitate to contact us to discuss how best to give your organisation the independent, expert assurances you need today.

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