KINGSLEY WOOD INSIGHTS

When Maternity Failures Are Systemic: What the Amos Investigation Means for Families

Amandeep Dhillon • August 28, 2026

On 30 June 2026, Baroness Valerie Amos published the final report of the Independent National Maternity and Neonatal Investigation. It is a national report, but its findings will feel painfully familiar to families affected by failings at individual NHS trusts. 


The investigation considered evidence from more than 10,500 women, birthing people and families, met more than 450 affected families, heard from more than 9,000 members of staff and examined maternity and neonatal services at 12 NHS trusts. Its conclusion was unequivocal: the system is fragmented, overly complex and too slow to learn. 


For anyone who has sat across a table from a mother whose baby has died, or whose child has been left with a serious and permanent injury, these findings are devastatingly familiar. 

The same failures, repeated

The Amos report follows the Morecambe Bay investigation, Donna Ockenden’s reviews of Shrewsbury and Telford and Nottingham, and Dr Bill Kirkup’s investigation into maternity services in East Kent.


Although each review arose from different events, the patterns are strikingly similar: 

  • women and families were not listened to, believed or properly involved in decisions; 
  • warning signs were missed, dismissed or acted upon too late; 
  • staffing, demand and capacity pressures contributed to unsafe delays; 
  • leadership and governance did not consistently identify or address risks; 
  • families encountered slow or defensive responses after harm occurred; and 
  • lessons were not reliably shared, implemented or sustained. 


In some cases, the decisive issue is measured in minutes: a concerning fetal heart trace that was not escalated, an urgent review that did not take place or an emergency caesarean section that was performed too late. A manageable clinical risk can then become a catastrophic and irreversible outcome. 


The report also records families’ concerns about internal investigations that appeared to downplay or reframe failings, trusts prioritising reputational protection over learning, and missing or altered records. These experiences deepen the original trauma. A family seeking a truthful explanation should not have to fight the organisation responsible for providing it. 


This is not a shortage of warnings. The investigation reviewed 895 previous recommendations concerning maternity and neonatal care. Its conclusion was that successive reviews and programmes had not consistently produced sustained improvements in everyday care. The problem is therefore not simply identifying what must change; it is ensuring that change is implemented, monitored and maintained. 

Inequality remains a patient-safety issue 

The report also makes clear that racism, discrimination and structural inequality are not peripheral concerns. They are safety-critical. 


Black babies remain more than twice as likely to be stillborn as White babies. Black women are almost three times as likely to die during pregnancy or shortly after birth as White women. Women and families also described differences in their care linked to socioeconomic status, language, disability and gender. 


Those figures cannot be explained away as unfortunate variation. They require urgent examination of how concerns are heard, how clinical risks are assessed and how care is delivered to women from different backgrounds. A safe maternity service must be an equitable maternity service. 

What families need after maternity harm 

I have spent much of my career acting for mothers whose babies have died, or whose children have been left with serious and permanent injuries, because their maternity care fell below the standard they were entitled to expect. 


When the Ockenden review into Shrewsbury and Telford was published, women contacted me because they recognised their own experiences in its findings. I went on to represent a number of those families and have since acted successfully for women in claims involving several NHS trusts. 


What those families usually want first is not compensation. They want to know what happened. They want an explanation in clear and honest language, based on a proper examination of the evidence, from people who are prepared to confront difficult conclusions. 


Too often, an internal investigation has not provided those answers. A specialist clinical-negligence claim may be the first time the complete maternity records, fetal heart monitoring, neonatal notes and relevant policies are examined independently by appropriately qualified experts. Depending on the issues, that may involve evidence from an obstetrician, midwife, neonatologist, neuroradiologist or other specialist. 


That independent analysis can identify whether care fell below a reasonable standard and, crucially, whether different care would probably have avoided the death or injury. It can place the chronology and medical evidence in writing, enabling a family to understand what happened and why. 

Why birth-injury claims are so demanding 

Maternity and birth-injury cases are among the most technically demanding areas of clinical negligence. 


The court must consider both breach of duty and causation. It is not enough to establish that care was substandard; it must also be shown, on the balance of probabilities, that the failing caused or materially contributed to the injury or death. 


Causation may turn on a narrow window of time, the interpretation of a cardiotocograph trace, the significance of reduced fetal movements, the management of infection or pre-eclampsia, or what a reasonably competent clinician should have done at 02:40 rather than at 03:10. NHS defendants may rely on expert evidence that the outcome was unavoidable or that earlier intervention would not have altered it. 


These cases therefore require early and forensic analysis of the medical records, careful selection of independent experts and a solicitor who understands both the medicine and the human reality of the case. Every request for instructions and every review of the chronology may require the client to relive the worst day of her life. The legal process must be rigorous, but it must also be trauma-informed and compassionate. 

Compensation is about rebuilding a life 

Where a baby survives with a serious injury, a claim is not simply about attaching a financial value to what happened. No award can undo the harm. 


Compensation can, however, fund the support that a child and family will need for life. That may include specialist care, therapies, case management, assistive technology, adapted accommodation, education, transport and compensation for lost earnings. It can mean the difference between a family being able to meet a child’s needs safely and being left to cope without adequate resources. 


In fatal cases, the available compensation may be more limited, but a properly investigated claim can still provide answers, recognition of failings and a measure of accountability. 

The wider problem of medical accountability 

The principles identified by the Amos investigation extend beyond maternity care. In my wider clinical-negligence practice, I also act in cases involving delayed diagnosis, failures to refer or investigate, surgical errors, inadequate consent, medication errors and failures in treatment or follow-up. 


The medical questions differ, but the essential task is the same: reconstruct what happened, test the care against the appropriate professional standard, establish whether the outcome could have been avoided and secure the redress the injured person needs. 

What must happen next 

Baroness Amos has recommended a new statutory Maternity and Neonatal Commissioner, together with a Modern Service Framework designed within 12 months and with rollout beginning within 18 months. The Government has also announced a national action plan, due in December 2026, and immediate measures including national standards for maternity triage. 


Those commitments are important. Their value will depend on implementation, independent oversight and a willingness to confront the cultural and structural problems identified repeatedly over many years. 


Families should not have to carry the burden of forcing the system to learn. Until consistent reform is delivered—and for those who have already been harmed—a properly conducted clinical-negligence claim remains an important route to independent scrutiny, answers, accountability and practical support. 


That is the work I do. 


If you or a member of your family has concerns about maternity care, a birth injury, the death of a baby or another form of medical treatment, specialist advice can help you understand what happened and whether further investigation is appropriate. 




Contact Kingsley Wood for a confidential initial discussion. 




This article provides general information only and does not constitute legal advice. The time limit for bringing a clinical-negligence claim depends on the circumstances, so specialist advice should be sought promptly. 

ABOUT THE AUTHOR

Amandeep Dhillon

PARTNER | DISPUTE RESOLUTION

He primarily specialises in clinical negligence, with a particular focus on maternity and birth injury claims, and also conducts serious and catastrophic injury litigation.

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