Every instance of avoidable harm is one too many.
For generations, the act of giving birth has carried within it both the promise of new life and, for too many, the shadow of preventable loss. England has now taken a formal step toward reckoning with that shadow — appointing its first maternity and neonatal commissioner in the wake of a sweeping review that found the nation's childbirth care system failing women through neglect, inflexibility, and embedded racism. The Amos review, nine months in the making, did not merely catalogue errors; it named a culture of dismissal that has cost mothers and babies their health, and sometimes their lives. Whether this new office can break a long pattern of recommendations made and forgotten is the question history is now asking.
- A 181-page review has declared England's maternity system unfit — not as a warning, but as a verdict backed by accounts of avoidable deaths, ignored pain, and women of color turned away or undertreated because of racism.
- The emotional and financial wreckage left on families who suffered preventable harm has been described as indescribable, and the NHS's current compensation process compounds that cruelty by forcing bereaved families to fight for acknowledgment.
- A new maternity and neonatal commissioner — widely expected to be Donna Ockenden, who led the Nottingham inquiry — will hold hospitals to account, co-chair a national taskforce, and attempt to rebuild trust shattered by scandal after scandal.
- Eight major reforms are on the table: overhauled triage services, independent family investigations, an end to discriminatory care, and a compensation system that leads with honesty rather than legal resistance.
- The review's own shadow falls over its promise — previous inquiries produced recommendations that were never fully implemented, and the resignation of a key clinical adviser over the report's framing signals that consensus remains fragile.
England is set to appoint its first maternity and neonatal commissioner, a role born from a nine-month investigation led by Valerie Amos — Labour peer, former cabinet minister — whose 181-page review concluded that the country's childbirth care system is fundamentally broken. Health Secretary James Murray announced the move as the findings landed, acknowledging a system that women described as dismissive, inflexible, and at times dangerous.
The review's portrait is stark. Women reported being ignored when they raised concerns. Some endured unnecessary pain during caesarean sections because pain relief was simply unavailable. Women of color described racism and discrimination that delayed their treatment and, in some cases, led to devastating outcomes. The financial and emotional toll on affected families, Amos wrote, has been indescribable — made worse by an NHS compensation process she called 'brutal' and 'cruel,' one that pits institutions against grieving families rather than offering swift acknowledgment of error.
The incoming commissioner will hold real authority: overseeing hospitals, ensuring reforms take hold, and co-chairing a national taskforce with the health secretary. An action plan is due in December. Donna Ockenden, who recently led the inquiry into the Nottingham maternity scandal, is widely expected to take the role.
Amos put forward eight major recommendations — urgent staffing and overhaul of triage services, the right for families to request independent investigations, a humane replacement for the current compensation system, and a direct confrontation with racism described as 'embedded throughout' maternity and neonatal care. She also noted a rare piece of good news: stillbirths and neonatal deaths are near record lows, though progress has stalled since 2020.
The report's release was not without turbulence. Dr. Bill Kirkup, a renowned maternity safety expert and one of Amos's clinical advisers, resigned hours before publication over a dispute about how 'normal birth ideology' was framed in the review. Amos characterized the disagreement as one of wording; Kirkup's departure nonetheless cast a complicated light on the moment.
Murray called the review a potential 'turning point' and pledged that the commissioner would ensure women and families are never ignored again. The review itself, however, noted a troubling pattern: past inquiries have produced sweeping recommendations that quietly faded. Whether this appointment finally breaks that cycle is the question England's mothers — and their children — are waiting to have answered.
England will soon have its first maternity and neonatal commissioner—a role created in response to a damning nine-month investigation that found the country's childbirth care system fundamentally broken. The appointment comes after Valerie Amos, a Labour peer and former cabinet minister, completed a sweeping 181-page review concluding that mothers and babies across England are being harmed by a system that is confusing, inflexible, and deaf to women's voices.
Health Secretary James Murray announced the move on the heels of Amos's findings, which painted a portrait of systemic failure. The maternity system, Amos wrote, is "no longer fit to consistently deliver high-quality, compassionate care to every woman and family." Women reported being dismissed when they raised concerns about their care. Some endured unnecessary pain during caesarean sections or assisted births because pain relief was unavailable. Women of color described experiencing racism and discrimination that delayed treatment and, in some cases, led to devastating outcomes. The emotional and financial toll on families who suffered avoidable harm has been, as Amos noted, "indescribable."
The new commissioner will wield significant authority. They will oversee hospitals, ensure improvements are implemented, and attempt to rebuild trust in a system that has been shaken by repeated scandals. The commissioner will also co-chair a national maternity and neonatal taskforce with the health secretary, which is drafting an action plan due in December. Donna Ockenden, who led last week's inquiry into the Nottingham maternity scandal, is widely expected to take the role.
Amos made eight major recommendations for reform. Maternity triage services—essentially the emergency room equivalent for pregnant women—need urgent overhaul with more staff so concerns are addressed faster. Families should have the right to request independent investigations if they are dissatisfied with a hospital's own inquiry into what went wrong. The NHS's current system for compensating harmed and bereaved families, which Amos described as "brutal" and "cruel," should be replaced with a process in which hospitals acknowledge errors immediately rather than fighting claims. Most fundamentally, the review called for rooting out racism and discrimination that is "embedded throughout" maternity and neonatal services.
The review found that many previous recommendations from earlier inquiries had either never been implemented or proved short-lived. Some maternity units are so outdated they are now unsafe. Widespread understaffing is compromising care quality and leaving maternity staff traumatized by their inability to prevent harm. Yet Amos did note one bright spot: stillbirths and neonatal deaths have reached near-record lows, though progress on both measures has stalled since 2020.
The report's release was complicated by the resignation of Dr. Bill Kirkup, one of Amos's clinical advisers and a renowned maternity safety expert. He quit hours before publication over a disagreement about the review's section on "normal birth ideology"—the principle that women should give birth vaginally without intervention whenever possible. Kirkup reportedly objected on principle to how this concept was framed, though Amos said the disagreement was merely about wording.
Murray called the Amos review a "landmark" report and a potential "turning point." He pledged that appointing the UK's first maternity commissioner would "drive lasting change and make sure women and families are never ignored again." Yet the review itself noted a troubling pattern: previous inquiries have made sweeping recommendations that were never fully realized. Whether this new commissioner will break that cycle remains to be seen.
Notable Quotes
The maternity and neonatal system in England is no longer fit to consistently deliver high-quality, compassionate care to every woman and family, and requires urgent reform to put safety at its centre.— Valerie Amos, in her review
Appointing the UK's first ever maternity and neonatal commissioners will drive lasting change and make sure women and families are never ignored again.— Health Secretary James Murray
The Hearth Conversation Another angle on the story
Why does England need a commissioner now, specifically? What changed?
The Amos review found that the system had become unfit for purpose—not just in isolated pockets, but systematically. Women were being dismissed, harmed, dying from avoidable errors. The government had to respond to that weight of evidence.
But there have been other reviews before this one. What makes this different?
That's the real question. Amos herself noted that previous recommendations often weren't implemented or didn't stick. A commissioner with real authority might actually enforce change, rather than just issuing reports that gather dust.
The review mentions racism embedded in the system. How does that show up in actual care?
Women of color described being dismissed, having their concerns ignored, experiencing delays in treatment. That led to unsafe care and, in some cases, devastating outcomes. It's not incidental—it's woven into how the system operates.
What about the doctor who resigned? Was he right to object?
He disagreed with how the review framed the idea that vaginal birth without intervention should be the goal. Whether that's a matter of principle or just wording is hard to say from outside. But it does suggest there's real disagreement about what good maternity care actually looks like.
If stillbirths and neonatal deaths are at near-record lows, how bad can things really be?
That's a fair point, and Amos acknowledged it. But progress has stalled since 2020. And the harm isn't just death—it's avoidable suffering, dismissal, trauma for families. The numbers don't capture the full picture.
What happens if the commissioner's recommendations also don't get implemented?
Then you're back where you started—a powerful report, good intentions, but the system unchanged. That's why the appointment itself matters less than whether there's real political will to follow through.