Baroness Valerie Amos’s investigation has delivered a stark and painful verdict. Families affected by NHS maternity failings continue to receive “unacceptable care” even after the tragedy has occurred. At a moment when compassion should be unconditional and support unwavering, the system is still responding with defensiveness, opacity and delay. It is a shameful indictment of how little has changed despite a decade of devastating scandals, from Morecambe Bay to Shrewsbury and Telford to East Kent. These were not isolated incidents. They were warnings that went unheeded.
The review lays bare a dual failure: a failure of safe care and a failure of accountability. The most harrowing finding is not only that harm has occurred, but that families are being forced through exhausting post-event processes that compound their trauma. Investigations drag on for years. Explanations are incomplete or withheld. Communication is inconsistent and bureaucratic. Families who should be prioritised as victims instead find themselves positioned as adversaries, compelled to fight for information, justice and compensation. The system seems more focused on protecting itself than supporting those it has failed.
Baroness Amos also highlights what many clinicians already know. Progress on reform has been painfully slow. Multiple inquiries have set out clear, evidence-based roadmaps for improvement, including safer staffing levels, better multidisciplinary training, psychological support for staff, and a culture where speaking up is expected rather than feared. Yet meaningful implementation remains patchy and inconsistent. Bureaucracy, competing pressures and entrenched cultural habits continue to stifle the pace of change. When a service faces chronic understaffing and rising acuity, it is difficult to build the learning culture it desperately needs. But this cannot excuse the inertia that has allowed preventable harm to persist.
The core issue is cultural. The NHS does not need another report telling leaders what to fix. It needs a clear line of accountability for failure to implement changes that have been mandated repeatedly. Maternity services require safe staffing as a baseline, not a stretch goal. Without adequate workforce and resource, safety is precarious and staff are pushed into impossible situations. But culture matters as much as capacity. Honesty, openness and compassion must become non-negotiable norms. Families should never have to fight for the truth. Trusts should proactively offer transparent explanations, meaningful apologies and early practical support, reducing both the emotional burden and the adversarial legal battles that so often follow harm.
Baroness Amos’s findings are more than an operational critique. They are a moral condemnation. They expose a system that not only fails families during their moment of deepest vulnerability, but continues to fail them long after the harm is done. Victims are being re-victimised by the very processes meant to restore trust. Until NHS leaders are held accountable for the pace of safety reform and the quality of post-event care, the cycle will continue. Maternity safety is not an area where slow progress is acceptable. Lives depend on urgency. The time for incrementalism is over. Families deserve not just safer care, but a service that responds to tragedy with honesty, humanity and unambiguous accountability.
