National Maternity and Neonatal Investigation Report- a letdown?

In this episode, Hannah Travis, Senior Associate in our Women’s Health team, sits down with Claudia Hillemand, Partner and Head of the Child Brain Injury team, to discuss their initial reactions to the National Maternity and Neonatal Investigation Report, published by Baroness Amos.

Together, they explore:

• The key themes emerging from the newly released report
• How today’s findings compare with the expectations discussed in earlier episodes
• Why the report represents a significant moment for maternity and neonatal safety
• Their early reflections on what the recommendations may mean for families, clinicians and the wider healthcare system

Listeners may remember that previous episodes covered the announcement of the investigation, its scope, and what our teams hoped the review would address. With the report now published, Hannah and Claudia share their first impressions and highlight the issues that stand out most urgently.

I’ve also zhushed up the asset by adding parliament. Do you think this works sort of blurring into our office pic or should I just use the parliament pic?

Transcript

SPEAKER_00 0:07

Welcome to the latest episode of the BBK Free Speech Podcast, brought to you by Bob Bud and Kemp, a leading firm of solicitors for serious injury claims. My name is Hannah Travis, and I'm a senior associate in a women's health team here at BBK, and I'm joined by Claudia Hillerman, partner of our child brain injury team. In these podcasts, we explore a diverse range of topics and issues with lawyers and barristers' external experts, and in the case of this episode, we're here to discuss our initial thoughts on the National Maternity and Neonatal Investigation Report published today by Baroness Amos. In previous episodes, we have explored our initial thoughts surrounding the announcement and the scope of the investigation and have discussed our opinions on what we're expecting to come out of it. The report only having been published this morning, there was a lot to take in. However, the overarching initial thoughts that we have we'll go over briefly today. Indeed, Hannah, thank you.

SPEAKER_01 0:57

And just as a reminder of how we got to this point, in June 24, the former Health Secretary Wes Streeting announced that there was this long-overdue national review into maternity services, the National Maternity and Neonatal investigation, and he appointed Baroness Amos as the chair. This was a clear indication to us all that maternity services were in crisis. And we knew this because of the long list of maternity scandals that have affected NHS trusts in East Kent, Workham Bay, Shrewsbury, Telford, Leeds, Sussex, Kettering, and Nottingham, which we had the report on quite recently from Don Ockerton last week. We've received this a weighted report from Baroness Amos today, and she has said that the NHS maternity system is not fit for the now and not fit for the future. Deeply concerning comments. She has made eight recommendations, and we're just going to run through them very briefly so that we have that in the back of our minds as we sort of pick out a few of those that have stuck out to us that we can comment on today. So the first one is the creation of a statutory maternity and neonatal commissioner to oversee change. The second is for the system, including the Department of Health and Social Care and NHS trusts, to take action to listen to the voices of women, birthing people, and families. The third, to improve the quality, transparency, oversight, and accountability of investigations, including a full explanation for families when death or harm occurs. The fourth, to create a modern service framework to set out national standards for responsive, safe and improved services. The fifth, to treat racism, discrimination, and inequality as a critical maternity safety issue, starting work immediately. The sixth for the modern service framework to include what she's referred to as streamlined national oversight and leadership model to have clear accountability. The seventh to improve culture and teamworking across the board, including those on the ward, on the trust boards, and in the government department. And finally, the eighth, to deliver states and digital systems that are fit for modern maternity and neonatal care. So lots, lots to take in there, Hannah. Very big job ahead, I think, to tackle even just one of these, never mind all eight.

SPEAKER_00 3:29

Absolutely. And um, I think what we're hearing, aren't we, um, Claudia, is mainly the response from families today about the report.

SPEAKER_01 3:39

We are, and sadly, we're hearing that a lot of families are bitterly disappointed, overwhelmingly disappointed. In fact, some have described their response as um and there's a feeling that I'm hearing that staff voices have been heard more than family voices. And of course, we need to hear all voices, and Barnes Emos needed to hear the voices of everyone involved, but there's a real cruel and unacceptable irony in the idea that families who have been identified as needing to be put at the center of this entire review and maternity services have been left feeling like this. When the whole point was inclusivity. And I think something that you flagged with me earlier, which I think really resonates, is that there are these calls for a public inquiry that we're going to talk about a bit later on. But our worry is that if families haven't felt listened to in this process, are they now jaded? Are they going to feel able and willing to take part in a public inquiry? Because if they don't feel like they've been listened to this time, they're gonna there's gonna be another, a further loss of trust. And let's not forget this is really potentially re-traumatizing for a lot of families to go over their story time and time again. And we know from the clients that we work with that a lot of parents, family members have PTSD as a result of what's happened. And sort of relive this experience over and over again is just re-traumatising and undermining any potential treatment that they're able to access.

SPEAKER_00 5:07

Exactly. And we we looked at the support really, um, Claudia, through the work that we do acting for injured parties, both babies and mothers, with that lens. So, what our clients are gonna be um looking at this, how we as lawyers acting for um families and seeking justice and actually bringing in compensation claims are gonna take this report and what they're gonna see from it. And one thing and a striking conclusion, um, which is considered to be quite controversial actually, is the finding by Baroness Amos that there was no evidence by her found of a normal birth ideology, which is said to be resulting in harm to mothers and babies. In fact, she said the evidence she gathered didn't allow us, allow her to determine that that was the issue. Um, she did hear from families that, you know, people feeling pressured or steered towards particular approaches to birth, which we hear all the time. And yet, you know, she also said that um staff were said not to recognise it, which just completely flies in the face of the evidence that we hear from our families and the people that we have to speak to on a daily basis. And in fact, quite controversially, Dr. Bill Kirkup of the previous Kirkcup review, and um he investigated maternity services in both Morkham Bay and East Kent, he actually disagreed with Baroness Amos over this, and actually that caused him to resign from um him advising on this inquiry, which, you know, to us says a lot. And actually, Baroness Amos just failed to fulfil, you know, her own terms of reference when looking into this by failing to determine the extent to which normal birth or ideology may have actually contributed to avoidable harm. You know, we we hear it unfortunately all all the time from the people that we speak to that you know, they're not listened to, they're forced into actions and methods of delivery that they just they have no control over. And it's just not what previous reports or inquiries have found at all. Um, it hasn't suddenly changed just in this short-lived review. Um, and it concerns me a little that there's an issue of bias here, or less weight given to the call for evidence that families, have you said, it's it wasn't an easy task for them to do. And to to have that conclusion is is quite striking.

SPEAKER_01 7:21

Um and it risks eroding the trust in this review, like we say. If if this finding is completely at odds with the experience of so many families that we represent and who have contributed, they're going to lose confidence, I would have thought, in a lot of the other findings.

SPEAKER_00 7:37

Exactly. And that's why families are said to be very disappointed and really quite upset and and as you say, re-traumatized by the findings made today. And you've only just got to look at the independent data that completely quashes this unrealistic finding. A separate survey found this week, actually, that the risk of serious birth injuries for women is actually rising in England, with 31 in every thousand facing hemorrhages or severe tears. And this trend is described as a national crisis. And MASIC, who are a charity who are dedicated to supporting women who suffered severe tears, they reported that in the first quarter of 2026 has actually seen the worst rate of recorded um third and fourth degree tears. Rates are actually up 46% on the same point five years ago. So it absolutely beggars belief that a normal birth ideology isn't evidence. And again, it's just another letdown for families who have been dismissed over and over again. It is.

SPEAKER_01 8:33

It is, Hannah. One of the other things that has come out of this is this idea of a modern service framework, so national standards being put in place. And this has been flagged by other uh review findings, the different practices within trusts and the need for an over overview, unifying standard for maternity care and neonatal care in England. Big job, though, isn't it?

SPEAKER_00 8:58

Big job. And actually, you know, this is one positive to come out from this because we want to take away the positives that this report obviously aimed to achieve. It's not going to make everyone happy, but it's it's a start. And for the first time, maternity and neonatal care in England could actually have a blueprint of, as you say, nationally agreed standards. And um really looking at personalised maternity care, what safe maternity care should look like, and having a clear roadmap and accountability mechanisms for how to get there and when things don't quite go right. One thing um we were talking about as well is there's a lot of unanswered questions about what the sanctions are likely to be for actually failing to adhere to that framework. And will it remove all internal trusts' own policies and procedures and this be the only way? Obviously, uh clinicians on the ground, they're gonna be working to what they've known for such a long time. It's gonna be a big change. Um, you know, and it has to really be a mandatory implementation. You know, all trusts must follow the same rules. That's what all inquiries have been calling for. And you need buy-in.

SPEAKER_01 9:59

You need buy-in from the people on the ground. But this is a is and I I don't want to try and find problems because I agree with you, there are positives to be taken here. But I do think we have to acknowledge that firstly, this framework isn't going to be produced until December. I mean, even that sounds ambitious, I have to say. But then it's like you say, it's the practical implementation of that, the retraining involved. That's huge. I just think that's actually going to take quite a long time. And how do we how will we know when things are better? This is this is really encouraging, but we know in our line of work and in many other lines of work, you have these things called SMART goals. Yeah. So you determine whether or not you've achieved something by whether or not you can answer yes or no. I just wonder if a lot of the suggestions and how measurable this is. How measurable it is. And how are we, are we going to be able to sit here and in one year, revisit these and say, did we do that? Yes. Did we do that? No.

SPEAKER_00 10:57

I I just worry that we don't have that tool in our And it's the volume um, you know, of potential recommendations. You know, some previous reports have had over 70 odd recommendations, and they're all so important in their own right. But, you know, the longer the list, the more difficult it's going to be to adhere to it. So it does need to be quite clear. And, you know, who's going to be writing them? We hope, you know, organisations such as the Birth Trauma Association and other uh charities who support families who have been injured are actively involved in this and they're brought in because they made some very important recommendations of their own in their previous birth trauma inquiry, which really do need to be taken forward. They're there already. So let's not reinvent the wheel. Um the work's already been done. So, you know, hopefully that'll be something to look into.

SPEAKER_01 11:42

We also are hearing a lot today, and this is coming from understandably from these disappointed families, are calling for a public inquiry. And I suppose for most people, the most recent public inquiry that would be in their minds is the COVID inquiry, the COVID inquiry. That's right. So Baroness Amos has fallen short of actually making this a recommendation. She has not made it a recommendation that there is a public inquiry. She has expressed that she understands and respects why some families are calling for one. I think she's commented that they can take a very long time and that really the focus should be on implementing her recommendations.

SPEAKER_00 12:24

But we can we can see both sides, I would say. This was always going to be a rapid systemic review, and sadly, it was never going to be able to dive into the deep-rooted issues and cover everything that all harm parents want it to. And obviously, she isn't against it, but it just falls short on recommending it, which I think was lacking for parents. And you've mentioned about the time it takes, and you know, families want answers, they want change, which is why this was meant to be a rapid review. And yes, we do know that they take um time and cost a lot of money, um, but it would be money well spent in circumstances of a national crisis. And you know, if the recommendations can be made alongside an inquiry, then fine. One concern would be for some families that um there's so much fatigue and having to share their stories again. And, you know, there is also a concern about like diversion of funds and resources and also the key personnel who could be making the changes now on the ground. And if they were then pulled into a lengthy inquiry, it could dilute some of the goods that will come out of the recommendations now.

SPEAKER_01 13:23

I think those are all really good points and valid. The one thing I would also point out is this concern about a lack of accountability so far. And we know that when the Donna Auckland review came out last week, when her report came out, a lot of senior management personnel did not cooperate with Donna Ogenden's report. And that is deeply disappointing and frankly insulting, I think, to a lot of families. And I think that is where a lot of the drive for a public inquiry is coming from. This idea that really we need to be able to compel senior figures who are key to the change that is recommended in this report to come forward, to reflect. And that's what we all do. That's in all industries, we reflect on why mistakes were made and what we can do differently next time. And I think there's a sense that that hasn't really fully happened here yet because of the failure to participate. But a public inquiry should address that, one would hope.

SPEAKER_00 14:27

I agree. And um, you know, families want to seek justice and answered for you know for what they've suffered, and that's considerably lacking in this report. There's a there's a lot of things that haven't been covered in report, you know, birthing injuries, uh, brain injuries to children, significant tears and and and things like that that hasn't been dealt with. So, you know, the the the public inquiry will be more far-reaching.

SPEAKER_01 14:48

The other thing that we are conscious of that hasn't really been touched upon in this report is the high rates and risk of maternal suicide.

unknown 14:57

Yes.

SPEAKER_01 14:58

And that is known to be a consequence of birth trauma. And actually, we know the Birth Trauma Association educate us on this a lot. And it's a leading cause of death in women six weeks and one year after pregnancy, but this report doesn't seem to engage with that, which is deeply worrying.

SPEAKER_00 15:17

It is, and especially for those families who have been and experienced that within their families. Um, you know, they know it's an important issue. And actually, I don't think you know many of the general public will realise that actually that has more deaths in the first year than infection in bleeding. In all of the you know, natural childbirth injuries that you'd kind of expect is actually suicide that is uh has the bigger figures and falling silent and a bit short on that is really disappointed for those families affected.

SPEAKER_01 15:46

And the other issue, Hannah, and this is what you see in your area of work, um, is around stillbirths and inquests.

SPEAKER_00 15:54

Yes. So the background here being, just to give everyone a bit of context, that stillbirths cannot currently be the subject of a cronial inquest. Um there's been no real commitment in the report. It's mentioned, it's got a whole chapter dedicated to it, but there's been no real commitment that this is going to change. It falls short of recommending mandatory stillbirth inquests. They're already being implemented within the UK. Northern Irelands have inquests for stillbirths. And it lets families down that a decision by Baroness Amos wasn't made on it one way or another. She's kind of sat on the fence of it a little. It just makes families of stillbirth babies feel like their harm is less of a concern and their pain is less important than a baby who has taken a breath but dies shortly after delivery. They should all be treated the same. And, you know, the reason why families would prefer inquests is that they are seen as more independent than current PMRT or MNSI investigations. You know, it's seen as a route to accountability when confidence or trust has been lost in the hospital's own investigations where families aren't put at the centre. And, you know, AMOS seems to be, well, it's going to be a bit difficult to kind of re-change the whole legal framework about the rights of a fetus. But why should that be a barrier? Just because it's complex or difficult doesn't mean it can't and shouldn't be done. This is all complex and difficult, isn't it? Exactly. It's it's it's, you know, that shouldn't be so something to be shied away from. And if that doesn't change, then we've seen again, people and we've all campaigned that NHS trusts are just still going to be incentivised to record a baby's death as a stillbirth to avoid that level of scrutiny. And it's just another level of accountability that won't change. Um, what she's done instead is call the government to release a response to an consultation, which I was surprised to read happened back in 2019, that they haven't responded to. The fact that it's been sitting there untouched for seven years is beyond me. Um, so hopefully her bringing that to the fore, compelling the government to actually take her um recommendations into account and actually respond to that will help families and all of us who are campaigning for that. And we'll we'll see what happens. Yeah, hopefully it'll provoke some change. Because it's really disappointing that the feel is like a missed opportunity. It does. Now, obviously, in our work, um, there was mention as well about course of change to the current clinical negligence compensation. Um, a little disappointed it's been raised in this limited report. When there's so many other issues, as we've mentioned, that haven't been addressed, such as physical harm to um to mothers and babies and suicide. So seem bigger than looking at the legal system. Um, it currently concludes that the compensation system is highly adversarial and actually often worsens the trauma experienced by bereaved and harmed families. But what we see, our views as lawyers, and you know, why families seek legal advice and pursue those claims is not the trauma experienced by going through the legal claim, it's the trauma and the mistrust because there haven't been those answers provided to them early on. Uh the answers just fall short. And the family should be supported day to day with you know quality of life. And you know, there shouldn't be any dispute as to the need for that.

SPEAKER_01 19:08

What we see time and time again, which is and can be traumatizing for families in litigation, is the amount of time it takes. And we have a number of cases where the hospitals fight, they fight the case only to eventually settle it years down the line, despite repeated invitations from us to engage at an earlier point to try and reach a resolution. And I think that's something that gets overlooked when we're talking about costs and money. Because if these cases could be addressed more quickly, then legal bills will go down. But that isn't the culture in the NHS at the moment. And it's just not what we see day to day despite our best efforts. This isn't a legal issue. People come to us because usually they don't want it to happen to someone else and they want answers. They don't have faith in the answers that they've got, and they find the idea of having an independent expert look at the treatment that they got reassuring because actually they don't trust what they've heard so far. So it all comes back to these issues and lack of faith around the accountability processes in the NHS. We know about the ENS scheme, the early notification scheme, and that's often discussed in the context of child brain injury, which is my specialism. Um, what I see in my day-to-day is that families engage with the early notification scheme. We can often get involved at an early stage with them, and I will always say, engage. There is no harm in engaging with this process. But once again, we have got another system where there's a lack of inclusivity for families. They're not involved in the they get a letter. They get a letter at the end with the outcome, they're not taken on the journey. In a case, they're taken on the journey because they have to be, yeah, you know. So there's a lack of inclusivity, there's still waiting times of sort of 18 months to two years. And a lot of the findings that I see are that either there wasn't anything done wrong, or yes, mistakes were made, but it wouldn't have made a difference. And then we go on to get our independent evidence, which has completely different findings that actually changes and of course that is going to happen because different we're all humans, all doctors who are looking at what happened may form different views. But there is a trend that I see that there is a disconnect between ENS findings and what our our investigations show. That's why I'd always encourage families who are involved in the ENS. Yes, get involved, but also seek independent legal advice. So you've got someone in your corner and it levels up the playing field.

SPEAKER_00 21:47

So worrying, isn't it? And you know, there's such talk about maternity claims and the figures involved. I mean, they are quite stark. Maternity claims count for 62% or 37.5 billion pounds of the NHS clinical negligence pot. But no one asks the claimant lawyers. And so the delays that we're seeing, the walls that are put up again by trust. And ultimately, the view is the harm was not there in the first place, the injuries haven't happened, there is no need for the compensation or the legal cost. So it's it's not a lawyer's problem, and it's not something that families should be avoided from seeking um justice. The harm stopped in the first place, which we're all hoping will start to see after these recommendations have been implemented, then that number goes down.

SPEAKER_01 22:35

I think what we don't focus on when we talk about the figures is the families behind each figure and each case and the injuries that mothers and children have suffered. And every penny is needed. This is not a windfall for any family. You ask any family, they in a heartbeat would swap compensation for this never having happened to their child or never having happened to the mother. And we know the legal principles that are in play mean that we have to account for every penny that we claim for families. So it's all needed.

SPEAKER_00 23:08

It is. I mean, there's been no immediate recommendations at the moment in adopting a no-fault compensation scheme, but it has brought it the conversation to a fore. It does call for a formal review to have a look at other models and to see if there is a less adversarial system that could better serve families. But whilst also, I think it's our message, still drives accountability, improves patient safety, and has an element of independence to it. Um, so yeah, we'll see. Um, you know, we'll be closely following the progress that's going to be made after today. And we'll come back in future episodes when the framework's been drafted and you know, once there's been more response perhaps from the trusts to the individual uh recommendations made against them. And we just truly hope that all the voices of affective families are just listened to and not diluted in any decisions that are made.

SPEAKER_01 23:59

Thank you, Hannah.

SPEAKER_00 24:00

Thank you. Join us again on the next episode of the BBK Free Speech Podcast. Please click and follow wherever you're listening to this podcast from to be notified of all future episodes. Thank you very much for joining us.