Baroness Amos’s Review Shows the Scale of the Challenge – and a Rare Opportunity for Change

The initial reflections published this week by Baroness Amos will have been difficult reading for many families, clinicians and organisations working across maternity and neonatal care. For those of us who support families living with the lifelong impact of birth injuries, the themes she highlights feel sadly familiar. In that sense, this report is not a complete surprise.

But it is an important moment. And it may be one of the best opportunities in recent years to create meaningful, lasting improvements in maternity and neonatal safety.

A picture we have seen before – but cannot accept as inevitable

Baroness Amos describes poor basic care, women not being listened to, communication failures at critical moments, a lack of empathy, and the profound impact of discrimination on outcomes. Families spoke about feeling blamed, unsupported, and excluded from reviews of their own care. These are not isolated experiences; they reflect patterns that have been identified repeatedly by families, campaigners and previous investigations.

Since 2015, 748 recommendations have been made across various inquiries into maternity and neonatal services. Yet harm continues, and families continue to navigate trauma that could and should have been prevented.

This accumulation of recommendations matters. It shows that the problems are well understood and that the challenge ahead is not a lack of insight, but how we finally translate knowledge into consistent practice and sustained improvement.

An opportunity for national alignment, not another report on a shelf

What feels different about the Amos review is the explicit intention to produce one set of national recommendations that address the systemic issues affecting maternity units across England. The scale of the review, and the early engagement with both families and staff, creates a chance to bring the sector together behind a single, actionable plan.

It also matters that the Health Secretary has placed such visible emphasis on this work. System-wide change will require leadership, resources, and accountability, and this review has the potential to create the conditions for that.

At the same time, it is understandable that some families feel apprehensive or disappointed. Many have lived through previous investigations and waited years for change that has been too slow or too limited. Their voices remind us that while this review can shape the future, we must also acknowledge the emotional weight and lived experience that families carry from the past.

Listening must sit at the heart of this reform

One of the most consistent findings across the review- and across the cases we see in our work- is that families often do not feel heard. Women know their bodies, and when their concerns are dismissed, vital opportunities to provide safe care can be missed.

Equally, clinicians have described the pressures they face, the emotional toll of criticism, and the impact of working within systems that are overstretched. The review recognises this and calls for better support for frontline staff. Safe, compassionate care relies on both families and staff being empowered, respected, and supported.

Creating a culture where listening is prioritised- for women, partners, midwives, doctors and bereavement teams- will be essential if future recommendations are to succeed.

The challenge ahead: turning hundreds of recommendations into real change

When the final report is published in the spring, it will add to an already extensive body of knowledge. The real challenge, arguably the greatest challenge, will be how the NHS, policymakers and regulators come together to implement change at scale and sustain it over time.

This will require:

• Clear national direction, but also space for local teams to innovate.
• A commitment to addressing inequalities, ensuring culturally sensitive and accessible care.
• Better communication with families, during pregnancy, birth, and after harm.
• Support for staff, recognising the emotional complexity of maternity work.
• Transparency and learning, not blame.

These principles are not new. But the Amos review has the potential to unite the sector behind them in a way that previous efforts have not quite achieved.

A moment to act with purpose and compassion

Families who have experienced loss or injury often speak to us about wanting something positive to come from their experience- a sense that their story might help another family avoid the same harm. This review has the potential to honour that hope.

At Fletchers, we see every day the lifelong impact that birth injuries can have on children and their families. We also see, in many parts of the country, dedicated clinicians providing outstanding care under extraordinary pressure. This review is not about faulting individuals; it is about understanding systems deeply enough to make them safer for everyone.

Real change will require collaboration, between families, healthcare professionals, researchers, regulators, and policymakers. If we can harness the collective will across those groups, then the spring recommendations could mark a turning point. The scale of the challenge is significant. But so is the opportunity.