Tag: ockendon

What NHS Boards are instructed to do about maternity in the light of the two heartbreaking reports.

These are the instructions sent to trusts.

This post first presents a copy of the letter sent to all trust and ICB boards about the Amos and Ockendon reports on Maternity by NHS England. Then there is a list of required actions.

We have been asked to publish this as not everyone has access to board papers, and many people are concerned about maternity safety. We as a campaign do not endorse all these actions. We think improved staffing is an absolute essential and this is not properly addressed. This post though is purely for information. We will publish our responses in detail soon. The reports are so detailed that we need time to read and process them. If you have had terrible experiences in maternity, be warned, the reports are truly heart breaking.

Love and solidarity to all who have lost babies or mothers in this horrible time.We also thank all the bereaved parents who made these reports happen. We honour them in campaigning for safe births for all.

A word of thanks to both these women is in order though, for the work and compassion in producing the reports. They do not criticize the staff in the way some of the press reports say they do. but they are ruthless in their criticisms of the services failures.

Our enduring thanks to the staff of the maternity services.

NHS England

Wellington House

133-155 Waterloo Road

London

SE1 8UG

30 June 2026

Dear colleagues,

Publication of Baroness Amos’ independent investigation into maternity and neonatal

services in England

Thank you for joining today’s event and contributing to our conversation about maternity and neonatal services. I don’t think anyone who attended today could have been anything other than deeply moved by what we heard and discussed.

This is a moment in our history that requires our collective leadership to act with real urgency in addressing the failings and harm experienced by women, babies and families and improve maternity and neonatal care.

None of this is going to be easy, but we all agreed today that this must be a turning point for maternity and neonatal services in the NHS. Women, babies, and families deserve better, as do our colleagues working in these services.

As set out during the event today, we have created a 10 Point Plan for maternity and

neonatal services (see Annex 1), taking those elements from Baroness Amos’ national

30 investigation and Donna Ockenden’s recent review that we must focus on delivering now.

This is a set of urgent actions in response to the recommendations in both reports that we are asking trusts and the wider system to prioritise.

These urgent actions will support, and report into, the National Maternity and Neonatal

Taskforce as it develops the National Action Plan, which will be published in December.

Further information and a reporting template will be shared soon.

In response to the Amos report, the government has also announced NHS England will

make £10.6 million available in 2026/27 to support the recruitment of newly qualified

midwives, helping them enter and remain in the NHS while strengthening frontline maternity capacity. See Annex 2 for further information.

The government also announced the creation of the UK’s first ever Maternity and Neonatal Commissioner, providing an independent voice to strengthen focus on safety, experience, equity and accountability for women, babies and families. Alongside this, an additional £41million will be invested to improve the safety and quality of the maternity and neonatal estate, supporting better environments for those using and working in maternity and neonatal services.

As we heard today, this must be a turning point for the NHS. Trusts and systems have already prioritised improving maternity and neonatal care, and progress has been made through the commitment and hard work of staff. We cannot allow failures in care to persist and be followed by reviews that continuously highlight the same themes.

Thank you for your leadership as we respond and move forward together with urgency to deliver lasting change for women, babies and families, and rebuild trust and confidence in maternity and neonatal care.

Yours sincerely,

Sir James Mackey

Chief Executive

New Document

1.Required actions

Listening to women and their families by rolling out Martha’s Rule

Commence roll out of Martha’s Rule across all maternity and neonatal services in

2026/27.

Building on the learning and insights from the recent pilot, this next phase will

support implementation in all antenatal, intrapartum and postnatal inpatient

maternity and obstetric settings, including maternity triage and assessment units,

and neonatal settings.

Implementation will be led by the national Martha’s Rule programme team,

working closely with patient safety collaboratives to provide coordinated local

support, webinars, guidance and advice.

We will contact provider organisations in the coming weeks to confirm

expectations, resources and timelines.

2.Listen to women and their families using realtime and transparently reported outcomes and experience and clinical audit data that are acted upon at board level

All trusts should implement a monthly cycle of collecting and analysing real-time

patient outcomes and experience data at their public boards, using locally

meaningful measures like the friends and family test, selected elements of PREM

(when available) and insights from maternity and neonatal voices partnerships

(MNVPs). This should include regularly listening to women, families and neonatal

parents at different points in the pathway, publishing data and patient commentary

for full transparency, and ensuring a clear focus on the experiences of people from

minority backgrounds. This will ensure the voices and experiences of women and

families are heard, scrutinised and acted upon by boards.

As part of this, trusts should also reinvigorate clinical audits focusing on key and

relevant recommendations identified in the Ockenden and Amos reviews in a

focused and effective way, and act on the findings.

The aim is to support this approach through national webinar

3. Dual board-level accountability between medical directors and chief nursing officers for maternity and neonatal care

All trusts must establish clear joint accountability at board level for maternity and

neonatal services, with medical directors and chief nurses holding shared

responsibility for oversight, performance and improvement. This must include

consistent medical director engagement alongside the chief nurse, and parity

between obstetric, midwifery, neonatal and operational leadership. Directors of

midwifery and clinical directors leading maternity and neonatal services should

attend boards when maternity or neonatal matters are discussed.

This should also be implemented across all levels in the NHS including at system,

regional, and NHS England boards to eliminate siloed working and strengthen

system-wide leadership

4.‘Amos into action’ staff listening exercise Following the listening conversation undertaken by Baroness Amos to understand the nature of the issues in maternity and neonatal services, NHS England will launch a full, open conversation with NHS staff and leaders to identify how the recommendations can be implemented across the system.

It will explore and help address the role of culture, attitudes, approaches to practice and ways of working – bringing staff into the single largest national conversation about what trusts and individual clinicians need to do differently to implement both the letter and spirit of the Amos recommendations.

This will be done in a way that aligns to rather than duplicates the work of the taskforce and will report findings into it. It will focus on how we implement Baroness Amos’s findings from the listening exercise and the findings of the Ockenden review of Nottingham University Hospitals NHS Trust (NUH)

5.inequalities in maternity and neonatal outcomes

We can now confirm the timeline for national rollout of the Perinatal Equity and

Anti-discrimination Programme, which will be available to all trusts by the end of

2026. The programme has been developed to support maternity and neonatal

teams to tackle racism and discrimination, improve the experiences and outcomes

of ethnic minority groups and those from deprived communities, and support staff

to work in environments free from discrimination and racism. All boards must

ensure that provision is in place to allow enough staff to be released to complete

the Perinatal Equity and Anti-discrimination Programme, with full participation

expected across multi-disciplinary teams.

Boards must also regularly review and act on trends identified by their inequalities

data dashboards: Maternity and Neonatal Equalities dashboard – NHS England

Digital

All NHS trusts providing maternity services are responsible for fully implementing

the Maternal Care Bundle by March 2027. This includes providing regular reports

to the trust board on implementation.

6.Ensuring 24/7 safety and responsiveness of maternity and neonatal services

All boards must take accountability for ensuring safe and effective service

arrangements, including reviewing staffing to ensure 24/7 availability and

responsiveness across key workforce groups.

Boards must also review internal resource deployment and consider whether roles

not directly supporting frontline delivery can be redirected to strengthen service

provision. Trusts must ensure that, where specialist posts exist (including in

bereavement care and infant feeding), other staff have the knowledge and skills to

ensure that care is not compromised when the specialist midwives are not

immediately available.

Commissioners also hold responsibility for ensuring that their maternity and

neonatal service model aligns to local demographic needs. Boards and

commissioners must address local gaps and eliminate siloed working to ensure

services can consistently and safely respond to the needs of women, babies and

families.

7.Trusts to review their homebirth services

Trusts have a continuing responsibility to offer homebirth as a choice for women

and are responsible for ensuring that they manage their workforce to enable this.

In November 2025, the Chief Midwifery Officer for England asked trusts to

urgently review the safety and quality of their homebirth services.

Trusts should ensure that this review has been undertaken and reported to their

board and that any safety concerns requiring urgent attention have been actioned.

They should ensure that improvement plans are in place where necessary and

that risks have been communicated to their regional NHS England team.

NHS England is working with partners to develop homebirth standards and a

homebirth framework, to support women’s autonomy, choice and personalised

care, and to help services provide safe homebirth care.

8. Responding to patient safety incidents, complaints and concerns with humanity,candour and a trauma-informed approach

Trust boards should review how they are responding to patient safety incidents,

complaints and concerns within maternity and neonatal services, with openness,

humanity and candour.

We will work with trusts, in alignment with the work of the national taskforce, to

develop a blueprint for how organisations and leaders can respond with more

humanity and compassion when things go wrong with a patient’s care.

9. Deliver safe and effective triage in maternity services (already committed by Government)

All trusts must commit to delivering safe and effective triage, starting by

completing a board-level audit within 3 months, with a focus on ensuring that

maternity triage services are consistently safe, responsive and appropriately

resourced. This will be supported by new NHS England guidance, which will be

published this week.

This includes having dedicated midwifery staffing to answer calls and provide

face-to-face assessments, separate from other services such as the labour ward.

Services should also have enough clinical, antenatal and bed capacity, with clear

escalation routes in place at all times, including overnight and at weekends.

Boards should have clear oversight of triage quality and performance, supported

by regular data on waiting times, assessment and review times, redeployment,

delays and outcomes. Triage records should capture women’s preferences, and

services should use evidence-based standards, such as BSOTS, supported by

rapid assessment training for triage midwives. This should enable trusts to identify

risks, address delays and provide women with timely, consistent and high-quality

triage care.

The outcomes of this audit should be reported to regions and the Department of

Health and Social Care / NHS England. Within 12 months, trusts must implement

improvements in line with national triage guidance to ensure women have

consistent access to high-quality, responsive triage across the NHS.

National maternity triage principles and a supporting measurement framework will

be provided to trusts this week to reduce unwarranted variation, strengthen

consistency in how concerns are assessed and escalated, and provide a clearer

basis for local, regional and national improvement.

10 Post death care (already committed by Government)

All trusts must implement actions set out in the System letter following the Fuller

and NUH reviews, including responding to the board assurance statement by 31

July and to the Human Tissue Authority requirement to review and assure

completeness of incident records over the past 10 years.

Every board should continue to review its local position and assure itself that all

deceased people cared for in NHS settings are treated with the respect, dignity,

security and compassion they deserve. This goes beyond compliance; it is

fundamental to compassionate care.

“Deeds not Words” for women giving birth!

Restore, Repair and Rebuild NHS maternity care after the Ockendon and Amos reports!

Donna Ockendon who conducted the Nottingham review
Valerei Amos who conducted the national review

In the last week of June, 2026, we saw two hugely significant reports on the damage to NHS maternity services. One report was from Donna Ockendon about long term harm done at Nottingham Hospitals. The other, the Independent National Maternity and Neonatal Investigation, was from Valerie Amos about the situation in ten other major hospitals. The reports describe brutal harm to so many women and babies.

Our love and solidarity go out to all whose pregnancy journey ended in achingly empty arms. Our hearts go out to families who lost their mothers and to the mothers so badly injured physically, emotionally or in their mental health. The additional pain when such an outcome could have been prevented is unspeakable.We send solidarity to those damaged by racism and to those women who were worst off financially and worst served by the Maternity service.

Save Liverpool Women’s Hospital Campaign says;

We demand immediate, significant and lasting improvements in the National Health Service maternity services across the country, in Cheshire and Merseyside and crucially in Liverpool. What we have known from women’s personal experiences has now been presented as formal reports. But many other reports raised the alarm before June 2026. Governments, NHS top bosses and the media knew what was happening long before recent reports and they clearly thought it acceptable, because they let the situation fester.

No ifs, no buts, no whining excuses. Things must change! Invest don’t cut! Babies not Bombs!

Deeds not words are required. We need the spirit of the suffragettes.

The New York Times photo archive via Picryl.com

For all our mothers, sisters, daughters, friends and lovers and for all the babies save Liverpool Women’s Hospital and every maternity hospital and service in the UK!

If these reports are brushed under the carpet as the twenty or more previous reports have been, this harm will be further normalized and the damage extended to ever more women and babies.

There must be immediate,and sustained improvements in the respect given to women, improvements in staffing, in resources, in buildings and equipment, and in management. No more cuts, no more bullying management!

Pregnant women, the communities, and the front-line staff must be included in decisions made about how these these improvements must look and feel.

We stand with the staff who kept the service afloat under terrible conditions. We acknowledge the Midwives who marched in 2022 and who are organising protests this year. We recognise that so many midwives left the profession in protest at the conditions in which women and babies were treated. We demand consequences for the government ministers, the senior managers and senior staff in the higher echelons of the NHS, and in Government, who saw the damage and ignored midwives’ and doctors’ complaints.

To women thinking of having a baby we say that even now most women have good outcomes. Some of the maternity services in the UK provide wonderful service. Do not assume the horrible conditions described in the reports from Donna Ockendon and Valarie Amos represent every birth.If you can, if you have the headspace, we welcome your involvement in this campaign.

picture credit Amanda Greavette

We demand safer working conditions and improved staffing for midwives, obstetricians, anesthetists and all the related workforce. The NHS needs more midwives, more obstetricians, and related professions, not as a one off but consistently over a decade.

All those involved in individual acts of cruelty, malice or neglect must be held accountable, but so must the senior administrators and politicians who knowingly allowed this situation to develop and continue.

Britain can afford a good maternity service. Not having good maternity services is far more expensive. Yet in July 2026 maternity hospitals including Liverpool Women’s Hospital are expected to make cuts. How is this justifiable?

The NHS began seventy-eight years ago when the country was far poorer and reeling from the damage – emotionally, physical, and financial, done by World War Two. Our city was one of the worst affected. Liverpool’s children were still playing in bombsites, as the NHS was founded. It is obscene for the government to pretend that today we can’t afford safe care. In 1948 the country decided it was important and invested in the NHS. In turn, this dramatically improved the lives of women and babies.

Women need a greater voice in the service. Women giving birth must be heeded and treated as adults. Women have had to fight for their rights before and will fight now.

The damage to maternity is echoed in so many other aspects of the NHS. We see the overcrowded hospitals and corridor care, the long waiting lists and the over worked staff, the neglected buildings and the money wasted on huge privatisation projects. We see the unfilled vacancies and unsafe cuts. We see the billions handed to big corporations from NHS funds and the unsafe care as treatments are outsourced to for profit companies. Demand that the NHS is restored, repaired and rebuilt!

Join us in campaigning for respect for women’s right to choose their own birth options, more respect for women giving birth, better staffing, and an immediate end to cuts. Every woman and man involved in this campaign helps make the future of maternity better.

Even as Donna Ockendon was conducting her harrowing review into Nottingham’s maternity failings, the local ICB closed the infant bereavement services at the hospital as a cost cutting measure. They knew what Donna Ockendon was doing and still went ahead with brutal cuts.

Don’t think that public indignation alone will make the government take lasting action. Long after the Grenfell fire no one has been punished, nor have other high rise blocks with cladding all been made safe.

Every woman who helps in any little way helps make the NHS safer, makes a difference. We have to build a large movement, deep in all our communities to secure the safety of mothers and babies, and that needs lots of women getting involved.

Fight like your nanas and great nanas did when they fought for and won universal healthcare, free at the point of need.

Mary Bamber, a working class woman fought in Liverpool a century ago for women’s rights and for healthcare for women.

Join us too in fighting for the future of Liverpool Women’s Hospital, the largest maternity hospital in the country. Sign our petition here. At least now the ICB can no longer keep saying integration into a main hospital is always safer. We know of many problems at Liverpool Women’s Hospital, it is far from perfect. However, Liverpool Women’s did not have the bad outcomes described in these reports. We thank the staff for that.

More than ten years ago Save Liverpool Women’s Hospital Campaign was founded to stop Liverpool Women’s Hospital being forced into Liverpool Royal, and to defend maternity services in Liverpool. We have fought on and on. Liverpool Women’s Hospital still on site. The fight goes on to get all the staff and funding it needs but more than 90,000 people have supported us. If you fight you might just win, but if you don’t you will always loose. The struggle for safe and respectful maternity care is a life and death struggle we need to win.

In the 1970s women fought for better maternity care, including letting partners into the Labour Ward, giving women a say in their treatment. That campaign reached many women. We did see change for the better. The charity Aims(Association for Improvements in the Maternity Services) is one of the organisations that was set up in the 1970s during that time of successful campaigning.

Please invite our campaign to come and speak at your organisation, however small. We will publish a more detailed comment on these reports when we as a group have had a chance to discuss them in detail. If you would like to be involved in such discussions please contact us on savelwh@outlook.com or by commenting on the comments section of the blog. For detailed background information see this article from Keep our NHS Public website.