Mariposa International Statement on the Baroness Amos Independent Maternity Review
Today marks another significant moment in the long journey to improve maternity and neonatal care across England. Baroness Amos’ report is an important contribution to that journey. It lays bare many of the systemic failures that have contributed to avoidable harm and rightly calls for stronger accountability, greater consistency, better leadership and a culture in which women and families are listened to. These recommendations deserve careful consideration and, more importantly, meaningful action.
Yet no single report can provide all the answers.
For many bereaved and traumatised families, this report will feel both encouraging and incomplete. It acknowledges some of the failures they have experienced, but it does not fully reflect the breadth of their voices, nor the lifelong impact that baby loss has on so many families. If we are truly committed to transforming maternity and neonatal care, then we must ensure every family is represented within that vision.
The publication of Donna Ockenden’s review, followed so closely by Baroness Amos’ report, reinforces the significance of this moment. Although these reviews each approach maternity care from different perspectives, together they paint a deeply concerning picture of the challenges that remain. Families cannot afford another cycle of thoughtful reports followed by inconsistent implementation. We have reached the point where identifying the problems is no longer enough. We must now demonstrate the determination to solve them.
There are clear areas of alignment with the independent Pregnancy Loss Review, which I had the privilege of co-chairing and writing on behalf of the Government. Each recognises the importance of listening to women and families, improving transparency, learning openly from mistakes and addressing unacceptable variation in care across the country. These principles matter because trust cannot be rebuilt without honesty, accountability and a willingness to learn.
The recommendation to establish an Independent Maternity and Neonatal Commissioner has the potential to provide the national leadership that has often been missing. However, if families are to have confidence in such a role, it must be genuinely independent, with the authority to challenge Government, NHS organisations and regulators without fear or influence. Independence cannot simply be part of the title. It must be reflected in the structure, powers and accountability of the role itself.
The report also introduces important proposals to strengthen national standards, improve maternity assessment and triage, support better clinical decision making and reform the current approach to investigations and compensation. These are welcome recommendations that have the potential to improve safety for thousands of families.
Alongside identifying failures, however, we must also learn from the maternity and neonatal teams already delivering outstanding care. Across the country there are remarkable professionals providing exceptional clinical care alongside extraordinary compassion. Their expertise should not remain pockets of excellence. It should become the national standard.
Every family deserves equal care, regardless of ethnicity, disability, postcode, language, age or circumstance. The independent Pregnancy Loss Review highlighted unacceptable disparities in care, including the inequalities experienced by Black and Asian families. Progress has been made, but it has not been fast enough, and much more remains to be done to ensure equitable care is not simply an aspiration but a reality for every family.
My greatest disappointment is that the voices and experiences of bereaved families are not given the prominence they deserve within Baroness Amos’ recommendations.
Baby loss is not a niche issue within maternity and neonatal care. It is an integral part of it.
Whether through miscarriage, ectopic pregnancy, molar pregnancy, termination for medical reasons, stillbirth or neonatal death, the impact of losing a baby is profound and lifelong. Every family deserves the highest standard of care, whether they leave hospital carrying their baby home, or carrying only memories.
No family should receive compassionate, specialist bereavement care simply because of where they live. Too many families continue to experience very different standards of care depending on the hospital they attend. Compassion should never be determined by geography.
Although important progress has been made in improving bereavement care across the NHS, implementation remains inconsistent. I would have welcomed a stronger commitment to ensuring every family, in every hospital, receives consistently excellent bereavement care, supported by protected specialist bereavement midwife provision, sufficient time, dedicated funding, appropriate resources and clear accountability.
Every professional working within maternity and neonatal services should receive mandatory training in bereavement care and compassionate communication. Families will remember clinical care, but they will also remember every conversation, every gesture of kindness and every moment they were shown dignity, or denied it. Compassionate communication is not an optional skill. It is fundamental to high quality maternity care and should become a consistent national standard.
Compassion is not separate from patient safety. It is part of patient safety.
The way families are cared for after tragedy shapes how they live with that experience for the rest of their lives. Clinical excellence and compassionate care are not competing priorities. They are inseparable.
Families often remember every word that was spoken and every kindness that was shown. Protecting time for memory making, creating lasting memories and allowing parents the opportunity to say goodbye with dignity should never be regarded as optional. These moments become part of a family’s story forever.
Families should also be recognised as genuine partners in their care. Information should be shared openly, choices explained honestly and decisions made together wherever possible. Listening is not simply about hearing concerns when something has gone wrong. It is about building relationships based on trust throughout every stage of maternity care.
Bereavement care cannot end when families leave hospital.
Families need continuity of care before pregnancy, during pregnancy, at the time of birth or loss, and long after they return home. Grief does not end at discharge, and neither should support. Timely access to specialist psychological support should be available whenever families need it, recognising that healing follows no timetable and every family’s journey is different.
The report also gives too little attention to families who go on to experience another pregnancy after the death of a baby. For many, a subsequent pregnancy is not simply another chapter. It is a journey lived alongside grief, fear and hope. These families often require additional reassurance, continuity of care and personalised support, yet too many continue to encounter fragmented services and inconsistent pathways. We should aspire to a maternity system that recognises the unique needs of every family, including those navigating pregnancy after loss.
The experiences of fathers and partners also deserve far greater recognition. Their grief, trauma and lifelong loss are too often overlooked, yet they, too, need support, understanding and compassionate care. They should never be expected to carry their own grief whilst simultaneously becoming the sole source of strength for someone else.
We must also care for the professionals who care for bereaved families. Midwives, obstetricians, neonatologists, sonographers, nurses, GPs and support staff walk alongside families during the most devastating moments of their lives. They cannot continue to do this well unless they themselves are given the training, time, supervision and emotional support they need. Supporting staff is not only an investment in their wellbeing, it is an investment in safer, more compassionate care for families.
The report rightly places importance on listening to women and families, but bereaved families must also be recognised as central to improving maternity and neonatal care. Parents whose babies have died, together with families whose babies survive with life changing injuries, hold some of the most valuable insights into where systems succeed, where they fail and how they can be improved. Their experiences should not sit on the margins of maternity reform. They should help shape it.
Improvement also depends upon honest data, transparent reporting and the courage to learn from every outcome. Families deserve openness, not defensiveness. They deserve organisations willing to acknowledge mistakes, understand why they happened and demonstrate clearly how lessons will prevent future harm.
There is also an important role for the voluntary sector. Organisations such as Mariposa International, alongside many other charities supporting bereaved families, hold decades of lived experience, practical expertise and trusted relationships with families. They should be recognised as valued partners in shaping, delivering and evaluating future improvements. Lasting change is strongest when families, healthcare professionals, policymakers and charities work together with a shared purpose.
One of the greatest strengths of the independent Pregnancy Loss Review was that it was built by listening to thousands of families and hundreds of healthcare professionals. It demonstrated what can be achieved when lived experience is treated not as an addition to policy, but as one of its foundations. The introduction of the Baby Loss Certificate is one example of what becomes possible when Government listens to bereaved families with humility and determination. We need to see that same ambition reflected in the next generation of maternity and neonatal reforms.
At the same time, we must recognise that no single review can transform maternity care on its own. Over many years we have seen the reports from Morecambe Bay, East Kent, Donna Ockenden, the independent Pregnancy Loss Review, Baroness Amos and many others. Together they represent an overwhelming body of evidence. While each has focused on different aspects of care, they consistently identify many of the same themes: the importance of listening, compassionate leadership, learning from harm, consistent standards, transparency and accountability.
The evidence is no longer the challenge.
Implementation is.
Families have lived through review after review, inquiry after inquiry, each bringing thoughtful recommendations and sincere promises of change. They should not have to continue waiting for the same lessons to be learned.
Success will not be measured by the quality of these reports. It will be measured by whether their recommendations are implemented with urgency, properly funded, consistently delivered and experienced by every family walking through maternity and neonatal services.
As one of the members of the Expert Reference Group serving the National Maternity Taskforce, and through my continuing work with the Department of Health and Social Care to support the implementation of the independent Pregnancy Loss Review, I remain committed to helping shape meaningful improvements across maternity and neonatal care. These roles provide an important opportunity to ensure that the voices and experiences of bereaved families continue to inform national policy and drive meaningful change. I do so carrying not only professional experience, but also the voices of the thousands of bereaved and traumatised families I have had the privilege of walking alongside over many years. Their courage, honesty and generosity in sharing their experiences continue to shape every conversation about improving care, and I remain determined to ensure those voices are never lost as these reforms move from recommendations into reality.
Despite everything that remains to be done, I remain hopeful.
I have seen what can be achieved when families are listened to, when healthcare professionals are empowered to lead change and when Government is willing to act. We have already seen meaningful progress, and that should give us confidence that further change is possible. But hope is not a strategy. It must be matched by leadership, commitment and sustained action.
This report is an important step forward.
It is not the destination.
For too many bereaved and traumatised families, the hardest questions remain unanswered. Too many parents still believe that their baby’s death, or the life changing injuries their baby sustained, could and should have been prevented. They deserve more than sympathy. They deserve answers. They deserve accountability. Above all, they deserve the reassurance that everything possible is being done to prevent another family experiencing the same heartbreak.
That is why I believe the time has come for a full statutory public inquiry into maternity and neonatal care in England. Not because we need another report to tell us what has gone wrong, but because families deserve an independent process with the powers to examine failures wherever they have occurred, hear directly from those affected, identify patterns that individual investigations cannot see and ensure that lessons are translated into lasting change.
A public inquiry should not duplicate the important work that has already been undertaken. It should build upon it. It should draw together the evidence from Baroness Amos’ report, Donna Ockenden’s work, the independent Pregnancy Loss Review, the Morecambe Bay and East Kent investigations, and the many other reviews that have exposed failings across maternity and neonatal services. Families should not have to tell their stories over and over again without seeing meaningful change. The purpose must be to create one clear, coherent roadmap for reform, with transparent accountability for delivering it.
The real legacy of every review will never be measured by the strength of its words. It will be measured by whether its recommendations are implemented consistently, properly resourced and embedded in everyday practice. Families have waited long enough. They deserve action that is visible not only in policy documents, but in consulting rooms, maternity units, neonatal wards and bereavement suites across the country.
As we move forward, every recommendation, every policy and every decision should begin with one simple question: Will this make life safer, kinder and more compassionate for families?
No maternity or neonatal service can promise that every tragedy will be prevented. Medicine will never be without risk. But every service can promise that every family will be treated with dignity, compassion and humanity, and that every loss, every serious injury and every concern will be met with openness, respect and a genuine commitment to learn.
That is the standard every family should be able to expect.
My hope is that this moment becomes a turning point. Not because another report has been published, but because we finally choose to act on the knowledge we already have. We owe that to every family who has bravely shared their story, every healthcare professional striving to provide the very best care, and every baby whose life has left an enduring legacy.
Above all, I want to acknowledge the extraordinary courage of the bereaved and traumatised families who have spoken so openly over so many years. Every improvement we have seen, and every improvement still to come, has been built on their willingness to relive the most painful moments of their lives in the hope that another family might be spared the same heartbreak. We owe them an enormous debt of gratitude.
The measure of any maternity and neonatal service is not simply how many babies it helps bring safely into the world. It is also how it stands beside families when the unimaginable happens. Families will not judge this moment by today’s headlines. They will judge it by whether fewer parents leave hospital with unanswered questions, whether more babies’ lives are protected, whether more families receive the compassion they deserve and whether no one is left feeling forgotten in their darkest hour.
Until every family can have confidence that every possible lesson has been learned, every avoidable death and preventable injury has been rigorously examined, and every bereaved family receives the compassionate care they deserve, our work is not done.
Zoe Clark-Coates MBE