Baroness Amos has demanded urgent reform of maternity triage services in England, after pregnant women who called the NHS with concerns were dismissed
The NHS must urgently revamp maternity triage services after babies died when mothers concerns which were ignored, a damning maternity review revealed.
It also found the NHS in England “is no longer fit to consistently deliver high-quality, compassionate care” for all. The probe chaired by Baroness Amos comes after a string of local maternity scandals and delivers a national verdict on changes needed.
It said pregnant women calling hospitals at the start of labour to report issues such as reduced foetal movement were often dismissed until it was too late. Baroness Amos’s team interviewed 450 families and received 10,500 written responses.
Opening her foreword, Baroness Amos said: “Words cannot describe the pain, suffering and trauma I saw and heard time and time again when talking to women and families about their experiences of maternal and neonatal care in England.
“Anticipation and joy turned into pain, distress and trauma. Questions left unanswered. Responsibility and accountability denied. Not heard. Rebuffed. Dismissed. Ignored.”
Baroness Amos has called for an urgent revamp of the maternity triage system which has become “the A&E service for pregnancy related concerns”. Her report stated: “All concerns, ranging from the straightforward to the most serious, often first present here. It is where time-sensitive clinical decisions are made and where inappropriate decisions or delays can have serious and irreversible consequences.
“Maternity triage often begins over the telephone, when women make contact with concerns about reduced baby movements, abdominal pain, bleeding, headaches, sickness or signs of labour.”
They visited 12 NHS trusts and heard from over 9,000 staff through surveys, site visits and interviews.
It comes a week after a report by top midwife Donna Ockenden outlined failings at Nottingham hospitals with a key theme that mums’ concerns were ignored on short staffed wards, which in some cases refused to admit them during labour. Avoidable harm included issues such as oxygen starvation, mismanaged labour, hospital-acquired infections and poor postnatal care. Ms Ockenden has said believes midwives are not trained to deal with the level of complications they now face.
Ministers commissioned the Amos review following a series of scandals at NHS maternity units and as maternal deaths are at a 20-year high. It outlined key themes including that NHS maternity care was not equipped to deal with “the changing profile of women giving birth and the increase in medical interventions”. It comes as women are now much older on average when they give birth and complications are more common.
The Amos review also found women were not being listened to or believed, resulting in avoidable harm. It said racism and discrimination were “embedded throughout the maternity and neonatal system”.
One woman told the Amos team how she waited in a corridor to be seen for four hours. She said: “They said there’s not enough room in the triage room, so we had to go and wait in the corridor… we were put in a [triage] bed at 2.10am and she was concerned with the baby’s heartbeat, so I was put on a CTG, and then just left.
“We were told that a clinician or a consultant or someone would come and have a look but then we were just left. I could see it [the baby’s heartbeat] going down, and down, and down, and then it was like going down, below 90, and we were just left.
“They said she wasn’t delivered when she should have been.”
The review found wards and infrastructure were often “not fit for purpose” and “overcrowding is common”. It added that postnatal wards “provide little privacy… in some units, women, birthing people and their babies share space with those who have experienced loss”.
Lady Amos said families should have the right to an independent investigation of their care when things go wrong and that they do not agree with the findings of internal NHS reviews. She said senior doctors should be on rotas 24/7 rather than relying on more junior staff over night.
The Amos review outlined national commendations based on previous local probes and its own investigations into maternity care at 12 other NHS trusts. James Murray, the health secretary, has committed to publishing an action plan based on its findings by December.
Baroness Amos recommended the creation of a statutory national Maternity and Neonatal Commissioner – accountable to Parliament – to drive reform of the whole NHS system. They would lead a new ‘Modern Service Framework’ to set minimum standards and hold NHS maternity units to account. The government has accepted it.
Health Secretary James Murray, said: “For too long women, babies and families have been failed by a system that didn’t listen. Their stories are heartbreaking and demand action. I am grateful to Baroness Amos for her work on this landmark review, which is a turning point. Appointing the UK’s first ever Maternity and Neonatal Commissioner will drive lasting change and make sure women and families are never ignored again”.
Baroness Amos said: “I still find it shocking that women and babies have been harmed or have died, sometimes as a result of failings in the maternity or neonatal care provided. We are a wealthy country. It should not happen.
“We heard from families who have lost friends or family members who were new parents or parents-to-be in tragic circumstances. It has taken courage to repeat painful and traumatic experiences. Some families told us they were prepared to share these experiences so as to prevent this happening to anyone else, ever again.”
Last week’s review into maternity care in Nottinghamshire by Donna Ockenden comes after she previously spearheaded a similar review into failings at Shrewsbury and Telford Hospital Trust.
Dr Bill Kirkup also led two earlier reviews of maternity failings in East Kent in 2022 and Morecambe Bay in 2015. Similar reviews are ongoing at Leeds Teaching Hospitals NHS Trust and University Hospitals Sussex NHS Foundation Trust.