Baroness Amos’ interim report into maternity and neonatal services makes for difficult reading, but health boards across the country are already starting to make changes.
Announced initially in June by health and social care secretary Wes Streeting, and headed by Valerie Amos, Baroness Amos, since September, 14 hospital trusts are being investigated as part of a rapid, independent, national investigation into maternity and neonatal services.
Her interim report – her initial thoughts into the inquiry – made for reading that was shocking, even for those inured to the poor state of maternity care across the country. Healthcare Today has consistently highlighted issues of maternity services at Swansea Bay University Health Board and those at Leeds Teaching Hospitals NHS Trust, to name only two.
“Nothing prepared me for the scale of unacceptable care that women and families have received, and continue to receive, the tragic consequences for their babies, and the impact on their mental, physical and emotional wellbeing,” she wrote.
Specifically, she highlighted the impact of discrimination against women of colour, working-class women, women with mental health challenges and younger parents; a lack of empathy, care or apology, both as part of clinical care and after things have gone wrong; and poor standards of basic care, among many others.
“I do not understand why change has been so slow. It is clear from what I have already seen that change is not only possible, but also necessary, and it is urgent,” she concluded, confirming that he final report and recommendations would be published in Spring next year.
The response to the interim report was pained recognition.
Sanja Strkljevic, partner at Leigh Day, said that it tells “a very familiar story”.
“We hear these kinds of issues raised again and again by mothers and families who come to us to try to achieve some kind of assurance that their experience will not be repeated,” she added.
Characterising poor maternity care “a widespread, systemic crisis,” her comments were echoed by Karen Reynolds, partner and head of clinical negligence at Freeths. “Our clients’ experiences reflect these same systemic failures highlighted nationally, including inadequate foetal monitoring and a breakdown in timely escalation of care,” she said.
Listening to mothers
But despite the permanent barrage of catastrophic news about maternity services in Britain, there are signs of change, and the message is beginning to get through. This year’s Care Quality Commission (CQC) maternity survey gives some indication of progress.
Many of the 16,755 respondents remain positive about their interactions with staff – particularly during pregnancy. The majority (89%) of those surveyed said they were “always” spoken to in a way they could understand by staff providing antenatal care (up from 88% last year), and over four fifths (81%) said that they were “always” given enough time to ask questions or discuss their pregnancy during antenatal check-ups, compared with 80% in 2024 and 73% in 2021.
“Listening to mothers at scale and learning from their feedback is an important way to manage risk and to improve services: findings from surveys like this one can provide an early warning where NHS trusts are too often failing to provide high-quality, person-centred care,” said Jenny King, chief research officer at Picker which coordinated the survey for the CQC.
The NHS is clearly paying attention too. At the beginning of December, it rolled out a new safety signal system across maternity services.
Named the Maternity Outcomes Signal System (MOSS), the tool rapidly analyses data being routinely recorded by maternity teams on wards to spot whether there are potential emerging safety issues which need urgent attention and action. If the system detects a pattern or trend in the data which seems out of the ordinary, it will send out a warning signal indicating a safety check should be urgently carried out on that unit.
“Having a signalling system for maternity which can carefully look at data in near real-time and spot early warning signs if something is potentially going wrong will help to avert safety incidents and prevent tragedies,” said England’s chief nursing officer Duncan Burton.
Once a signal is generated, it is mandatory for the maternity unit to carry out a critical safety check within eight working days and share action taken with regional and national teams. Signals will be traffic-light coded, with amber alerts representing a 95% confidence and red alerts, a 99% confidence that the increase in events is real and needs urgent attention.
The system is now being rolled out across all maternity services in the country, and both the data and signals will be visible at a trust, Integrated Care Board (ICB), regional and national level.
“I welcome this move as it places earlier scrutiny and accountability at the centre of maternity safety, with a proactive approach to maternity safety, focusing on prevention rather than the traditional reactive response after incidents occur,” said Erum Anwar Khan, national maternity improvement advisor at NHS England.
Another layer of reassurance
At a local level, changes are also being seen. At Medway NHS Foundation Trust, a patient safety initiative that allows patients or their friends or family to request an urgent review of care if they think deterioration is being missed by clinicians has recently been extended to cover The Oliver Fisher Neonatal Unit and the children’s wards.
The Call 4 Concern (C4C) programme, which was initially launched by the hospital in January 2023 for adult inpatients, has been rolled out across the two services.
It enables patients, friends and family to call a dedicated number for immediate help and advice, directly from a member of the Trust’s acute response team, if they still have ongoing concerns about their own or their loved ones’ changing condition despite raising their concerns with the nurse in charge or doctor.
Set up as a response to Martha’s Rule, a member of the team will then visit the patient on the ward to discuss any concerns and assess the situation before liaising with the patient’s medical team and other healthcare professionals to discuss further treatment options. A note of the C4C intervention will then be logged in the patient’s notes, summarising the concern raised and any actions taken.
“We already have robust systems and processes in place to detect when a patient’s condition worsens, but Call 4 Concern provides another layer of reassurance for our patients and their families,” said the Trust’s interim chief executive Jonathan Wade.
As Neil Rowe, head of practice at Maulin Law, comments: “Since its launch, the Rule has already delivered hundreds of critical, potentially life-saving interventions”.
A challenging situation
Speaking at the MacDonald Obstetric Medicine Society annual meeting in mid-December, Anthony Nicoll, the Scottish government’s senior medical officer for maternal and women’s health, responded to Amos’ interim report by admitting that “we’re in a really challenging situation within maternity services” and that “the picture is very similar in Scotland”.
There have been three Healthcare Improvement Scotland safe delivery of care inspections of maternity units in Scotland this year. All have been found lacking. The inspection, at Ninewells Hospital in NHS Tayside in June, found good teamwork and compassionate care, but concerns specifically about how patients were assessed and treated. The maternity services inspection at the Royal Infirmary of Edinburgh in November, damned the culture, oversight of patient safety and staff wellbeing. And at the beginning of December, the report into maternity services at Forth Valley Royal Hospital, NHS Forth Valley, raised significant safety issues.
But the government has taken notice. Nicoll outlined that a task force that had been set up by the Scottish government to “provide strategic oversight for quality improvement in maternity services” and will be able to look at data and support policy information, as well as learning across maternity care. This is being done at the highest level. The task force will be chaired by Neil Gray, the cabinet secretary for health and social care, and will have its first meeting in the New Year.
“Having this task force will give us this opportunity and this reassurance to improve maternity care services in Scotland and deliver that continuous improvement,” Nicoll said.
The interim report from Amos might be a brutal wakeup call, and no one would disagree that it is happening later than it should have, but healthcare across the country is paying attention, and real improvements to maternity safety are already beginning to happen.
