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.