The publication of Baroness Amos’s Independent National Maternity and Neonatal Investigation (the Amos Report) is far from the first investigation into maternity care in the UK. In fact, there have been a series of maternity scandals and local reviews that have identified recurring problems in maternity care. This includes the recent report by Donna Ockenden into Nottingham University Hospitals NHS Trust, published a week before the Amos Report.
In November 2015, the then Health Secretary, Jeremy Hunt, made a pledge to reduce the rate of maternal deaths, neonatal deaths and stillbirths by 50% by 2030. According to the most recent data, we will not meet this pledge. Stillbirths remain above pre-Covid levels and maternal deaths are at a 20-year high. The NHS reports that maternity claims cost the NHS more than £2 billion per year and account for 51% of all clinical negligence claims.
It is clear that there are issues with maternity services in the UK. In this article, Vanessa Harris, partner in our medical negligence team, explores the recommendations made in the Amos Report and the Ockenden Report and consider whether either is likely to drive change in maternity services.
Limitations
While Donna Ockenden sought to set her review in the national context, it was inevitably focused on care provided at a single trust.
Due to the rapid turnaround of the report, several key issues in maternity care were not addressed in the Amos Report and, following its publication, the report has been widely criticised in this regard:
- Dr Kirkup, who had been involved in the investigation and had previously published a report in relation to failings at Morecambe Bay NHS Foundation Trust, resigned from the investigation prior to publication of the report. He argued that investigators had found evidence suggesting that issues relating to “normal birth ideology” still existed in some places and believed the report should have criticised this more explicitly.
- MASIC, which met with Baroness Amos as part of the investigation, published a damning response to the report, stating: “Having met with Baroness Amos during the evidence-gathering process and discussed at length the consequences of maternal birth injury and mechanisms to aid prevention, we are so disappointed there is no mention in the report of Obstetric Anal Sphincter Injury (OASI), the impact of forceps, or the psychological impact of traumatic birth.”
- The Maternity Safety Alliance was also highly critical of the report and questioned whether the investigation was sufficiently independent. It continues to call for a statutory public inquiry into maternity services.
Findings
As with previous investigations, the Ockenden Report found that many of the same issues in maternity care were present in Nottingham as in maternity services across the country. Unsurprisingly, the Amos Report also identifies many of these issues.
1. Women and families were not listened to
The failure to listen to women has been a recurring theme in many investigations into maternity care. Frequently, when women raise concerns about their babies or themselves, they are made to feel that they are overreacting.
Donna Ockenden notes that “many women reported feeling dismissed, disempowered, or blamed when expressing anxiety or reporting symptoms involving reduced fetal movement, pain, hypertension and postnatal deterioration. Families repeatedly described circumstances in which they felt they were not listened to until clinical situations became critical.”
Baroness Amos identified that “nowhere was it more apparent that the voices of women … were ignored or dismissed than in the triage process … my assessment is that if triage services are improved, lives will be saved and harm reduced.”
However, it is not only in clinical situations that women and families are not listened to. It is also when they raise concerns about care that has been provided. The Ockenden Report highlights a “fear of speaking up, dismissive attitudes becoming normalised, defensive behaviour from staff, families feeling ‘gaslit’ or blamed …”. The Amos Report highlights the focus on reporting incidents only where trusts believe they are at fault and the lack of sufficient redress where harm has been caused and families have concerns.
Both reports highlight failures in communication, the duty of candour, openness, transparency and responsiveness to patient voices.
2. Failure to learn from adverse events
The Ockenden Report highlights failures in incident reporting, with incidents being misclassified or downplayed, failures to comply with the duty of candour, and failures in relation to serious incident investigations, including significant delays. Donna Ockenden concluded that, as a result of these failings, similar incidents recurred and patients suffered avoidable harm.
The Amos Report also found that “despite numerous types of investigations, these investigations were failing to drive improvements and make meaningful differences to the safety and quality of care delivered to women”. Baroness Amos also found that there was “a system that appears to be unable to learn from its mistakes“. Like Donna Ockenden, she identified instances “where harm had occurred and no investigation or review was undertaken because staff judged there to be no errors in the care provided”.
The Ockenden Report found that, too often, because of inadequate reporting and investigations by the trust, “consequences continued to be realised through legal and regulatory processes”.
3. Poor culture and weak leadership
Both reports found evidence of a poor working culture within maternity care. The Ockenden Report highlighted significant historical issues, including bullying and a culture of individual blame and fear, which made staff reluctant to escalate concerns. The Amos Review also found that 27% of obstetrics and gynaecology trainees reported being hesitant to escalate concerns.
The reports also identified issues with leadership and governance. There is poor accountability when things go wrong and a defensive culture often develops. Initially, incidents are minimised or under-reported. However, even when they are investigated and issues are identified, leadership is often weak and too often no action is taken. The Ockenden Report found that even when external investigations identified failings, the issues were “sidelined and ignored, deemed too difficult or of insufficient priority”.
4. Staffing pressures
Both reviews highlighted workforce shortages and staff burnout. There are significant staffing gaps in maternity care across the country. In the Ockenden Report, the specific issues with bullying and workplace culture led to significant staffing challenges.
However, the Amos Report also places considerable emphasis on the challenges facing staff in maternity services. It highlights the importance of safe staffing levels and ensuring that there is an appropriate mix of staff on each shift. The report also identifies significant workforce pressures caused by shortages, rota gaps and high absence rates. In addition, it highlights a failure to provide protected time for training, learning and improvement.
Recommendations
The Ockenden Report was published at the end of a four-year period during which there had already been extensive scrutiny of the maternity care provided by Nottingham University Hospitals NHS Trust (NUH). The report acknowledges that these previous interventions had already led to significant improvements in maternity services at NUH.
While the Ockenden Report considers the national picture in relation to maternity care, its primary focus is on changes required at NUH to improve maternity services at that trust. Despite the improvements already made, the report identifies several areas requiring further improvement:
- Listening to women and families as the foundation of perinatal care.
- Perinatal workforce planning and funded safe staffing.
- Training and multi-professional learning.
- Escalation and clinical oversight.
- Risk assessment throughout pregnancy.
- Incident investigation and family involvement.
- Governance and board accountability.
- Culture, teamwork and psychological safety.
In contrast, the Amos Report examined the national picture and how maternity services could be redesigned at a national level to reduce harm. The investigation produced eight national recommendations aimed at long-term transformation:
- Creation of a Maternity and Neonatal Commissioner.
- DHSC, NHSE, Integrated Care Boards (ICBs) and NHS trusts must take action to listen to the voices of women and families within 12 months.
- DHSC, NHSE and the CQC must improve the quality, transparency, oversight and accountability of investigations to ensure that learning is captured within the next 12 months.
- DHSC and NHSE must design a modern service framework for maternity and neonatal services within the next 12 months.
- DHSC, NHSE, ICBs, NHS trusts, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) must treat racism, discrimination and inequality as critical maternity safety issues within 12 months, with work beginning immediately.
- DHSC and NHSE must clarify existing system governance, oversight and accountability structures and improve the effectiveness of regulatory oversight within nine months.
- DHSC, NHSE, ICBs and NHS trusts must work with colleges, universities, postgraduate educators and others to improve culture and teamwork, and strengthen leadership at all levels and across professions within 12 months.
- DHSC and NHSE must deliver estates and digital systems that are fit for modern maternity and neonatal care, supported by 12-month, five-year and 10-year investment commitments and implementation deadlines.
While these recommendations are positive, any assessment of their likely impact must be considered in the context of what has gone before.
As stated by the Lily Mae Foundation in response to the report:
The history of maternity care in England is littered with vital recommendations that were never implemented. That cycle has to end.
In the press conference accompanying the publication of the Ockenden Report, Donna Ockenden stressed that her eight areas for immediate and essential action were not merely aspirational but necessary and must be implemented. She noted that recommendations she had made in her previous report remained largely unimplemented.
The Amos Report also acknowledges that many recommendations from previous inquiries have not been successfully implemented.
Conclusion
Ockenden’s impact
While Donna Ockenden was clearly frustrated that many of her previous recommendations remained largely unimplemented, the review she undertook shone a spotlight on maternity services and helped drive a national conversation about maternity care.
The Nottingham review is likely to have an even greater impact, coming at a time when maternity services are under intense scrutiny. Donna Ockenden is now a powerful voice in maternity safety. She has made it clear that the urgent actions set out in her report must be implemented and is well placed to maintain pressure for change.
Amos’s impact
The Amos Report sets out some clear requirements and timescales for government, including the establishment of a National Maternity and Neonatal Taskforce and a National Maternity and Neonatal Commissioner. However, some recommendations are less specific, such as the requirement to “drive improvement in the quality, transparency, oversight and accountability of investigations”.
It remains to be seen whether these recommendations will be fully implemented.
Perhaps, taken together, these reports will have a greater impact than either would have achieved individually. The central message of both reports is that maternity care is failing and requires urgent reform. Both highlight shortcomings in listening to women and families, learning from mistakes, and accountability at the highest levels. Both also identify significant challenges relating to staffing, training and leadership. Hopefully, the momentum generated by both reports will prove too strong to ignore and meaningful reform of maternity services will follow.
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