Scala supported groups of bereaved and harmed families in preparing and distributing statements on the National Maternity and Neonatal Investigation's final report by Baroness Amos: the Maternity Safety Alliance, comprised of families from across the country, and Truth for Our Babies, comprised of families affected by negligent maternity care at University Hospital Sussex NHS Foundation Trust.
Statement from the Maternity Safety Alliance:
"It is now clear, as we feared, that this investigation does not meet the standard of independence expected of a national inquiry, as the investigation team itself included personnel from NHS England and HSSIB. Lobbying by special interest groups has influenced key recommendations, including the proposal to establish a maternity commissioner.
The recommendation for a maternity commissioner in the format proposed by Baroness Amos is fundamentally dangerous, concentrating power and responsibility in one pair of unaccountable hands. This person will not be meaningfully independent and will not be able to create real change.
The investigation has failed to address core issues at the centre of maternity failings and is marked by a clear lack of scrutiny. It does not analyse regulators such as the GMC and NMC at all, or in any useful depth regarding the CQC. It has also failed to fulfil its own terms of reference, including by failing to determine the extent to which normal birth ideology may have contributed to avoidable harm.
There is no examination of areas such as post-death care in this report, despite this being a critical issue in Nottingham’s independent review. There, it prompted a wider re-evaluation of maternity care by exposing the inhumane treatment of babies after death. It is difficult to believe that such failures are isolated, raising concern about what other unknown issues remain outside the limited scope of findings in this report.
The findings and recommendations of the Amos investigation constitute a misdiagnosis and therefore, if taken forward by the Secretary of State, risk making maternity care even more dangerous.
Many of the recommendations are overly aspirational and have no hope of being implemented as the fundamental causes of avoidable deaths and avoidable harm remain untouched by the Amos investigation.
While time was being wasted on this inadequate investigation process, an additional 814 babies have died avoidably in the NHS. The lives of 814 children are the true cost of this report.
Despite promises to the contrary, the Amos investigation has left huge gaps in analysis and understanding of what has gone wrong in maternity care, and crucially why avoidable deaths and avoidable harm persist despite multiple investigations and reviews.
Evidence from the Nottingham review has highlighted the severity of failures in maternity care, reinforcing the growing consensus for a statutory public inquiry.
A statutory public inquiry is now urgently needed to give us the full truth of what is happening in maternity care across the country, and to give us effective and sustainable solutions.
Such an inquiry must analyse: regulators including CQC, GMC and NMC; local and national oversight and investigatory bodies including ICBs, NHS England and MNSI; education and training provision for midwives and doctors; the influence of the third sector and academia; and political decision-making.
This is not just a matter of learning: we deserve answers as to why our children were avoidably injured and killed, and why the people responsible for ensuring safe maternity care failed to act even when the problems were known."
Statement from Truth for Our Babies group:
"This process was never the in-depth investigation that we, the families, were promised. The report’s surface-level conclusions only confirm what we have known for a long time – that it was never capable of delivering the scrutiny or answers that will fundamentally improve maternity safety in England.
Regulators have not been properly examined, despite the report clearly identifying systemic failures. Instead, the investigation has been carried out within the very system that allowed these failures to happen, with personnel from NHS England and HSSIB on the investigation team. To us, it feels like the system has been allowed to mark its own homework.
We shared our experiences in the hope that this would finally lead to truth and accountability. Instead, what we see reflected is a process reliant on short visits, surveys, and surface-level impressions - not the detailed case-by-case examination that is needed to understand how babies died and families were harmed.
UHSussex was one of the 12 Trusts visited by Baroness Amos, and those of us who attended the family panels opened up about how traumatising our experiences at the Trust have been - the mistakes that were made, how those mistakes were repeated across cases, and how we were lied to and things were covered up. But that reality has not come through in the report into Sussex. Instead, it feels airbrushed and like a misrepresentation of our experiences, and it is incredibly difficult to understand why what happened to us has been minimised in this way. It demonstrates the necessity for the upcoming independent review of UHSussex maternity services, led by Donna Ockenden.
The UHSussex report does highlight the following issues in maternity safety at the Trust:
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The positive data of patient experience presented by the executive team was at odds with some of the experiences shared in the family panels, including recent experiences of bereavement and harm.
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The investigation team was concerned that a strong learning culture did not appear to be embedded.
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Staff raised concerns about patient safety, unsafe staffing levels and issues such as bullying of staff when they tried to raise matters of patient safety.
The report itself recognises that investigation systems are failing families, that they are superficial, defensive, and fail to provide answers. But this process has repeated many of those same failures.
We were promised that this process would be done with us, not to us. Instead, many of the families were asked to relive deeply traumatic experiences without being meaningfully included in the investigation. We spent days and weeks providing detailed feedback on the investigation team, the process, and the terms of reference. Ultimately, none of these contributions were listened to, and we were eventually told that co-production with the families was not possible.
In the UHSussex review, the suggestion that staff morale has been impacted by negative media is particularly difficult to read and feels misplaced because that attention exists because of what has happened to families like ours. The handling of the report’s release has only compounded this harm. We were sent an embargoed copy the day before publication, without sufficient time to process its contents or provide feedback, before widespread media inquiries began. This approach has been anything but trauma-informed and has caused further distress to the families, repeating the same patterns of harm experienced at the outset of the process.
This maternity investigation has felt like yet another attempt to build a picture without all the pieces of the puzzle. Until there is a truly independent national investigation - one with real powers to hold organisations and individuals to account for the avoidable harm and deaths in maternity services, and one that works with the bereaved and harmed families - nothing will change.
That is why we support calls for a Statutory Public Inquiry - so that we can finally have a full understanding of how this harm is enabled and make sure no other family has to go through what we have."
