The National Maternity Investigation: A review for show not for change – why the rapid review risks failing families and babies.

A focussed critique of the rapid national investigation into NHS maternity and neonatal services

No statutory power:

• Trusts are only required to cooperate with the rapid review on a voluntary basis, with no obligation to disclose evidence, provide testimony, or comply with findings.
• There are no sanctions for non-cooperation or non-compliance.
• The rapid review has largely excluded regulators (those responsible for ensuring accountability), in particular the CQC, NMC, and GMC.
• Baroness Amos told affected families that the investigation “will not deliver justice” and admitted in a consultation that scope was a limitation in the rapid review.
• The rapid review is not capable of reviewing a trust alongside an ongoing criminal investigation and therefore shouldn’t be happening as it risks contaminating any potential future evidence.

Compressed timescale:

• The review has a compressed timescale with an unprecedented number of Trusts under investigation.
• Amos/her team are spending approximately two days at each Trust, which is insufficient time to assess the clinical practice, governance, culture, leadership, data, and the range of lived experiences of the staff
• Amos/her team has focussed on speaking to senior leadership at each Trust, which is an ineffective approach to expose their failings.
• At best, it’s a sampling exercise, not an investigation, which would require iteration and follow-up.
• Speed and optics take precedence over truth, transparency and the lived reality of families failed repeatedly by the maternity system.

Repetition of known failures:

• Several Trusts included in the rapid review have already been found by the CQC to require immediate improvements to maternity services (Gloucestershire, Blackpool, and Somerset)
• Others (East Kent, Shrewsbury and Telford, and Morecambe Bay) were explicitly chosen because they have been the subject of earlier independent inquiries.
• Shrewsbury and Telford were subsequently excluded at short notice with no real notice given to either local families, MPs or the Trust.
• This indicates that core problems within many of the selected Trusts are well-documented and long-established.
• The issue is therefore not the failure to identify the problems, but a failure to implement changes and account for previous findings. 
• The hospital visits by Amos/her team are no different to an announced CQC inspection; the hospitals knew when these would take place, allowing them to prepare, (for example have improved staffing) and manage what is visible during the visit rather than exposing routine practice.
• The rapid review is positioned to restate known failures rather than confront the lack of repeated Government and regulatory action and accountability that has allowed these problems to continue.

Marginalisation of the families:

• Despite Wes Streeting’s public statement that “the investigation team and terms of reference will be co-produced with the victims of maternity scandals” and the DHSC’s continued false claims about the families’ input, their involvement has been limited to sharing their experiences rather than participating in the decision-making processes.
• The trauma informed element of the investigation is token and has caused significant distress.
• The investigation team was appointed without the families’ knowledge or consultation, as was the terms of reference, both of which they learnt about via the media.
• The families were presented with four potential chairs of the investigation, three of which were wholly unsuitable due to their backgrounds in the NHS: Sir Bruce Keogh (former medical director of NHS England); Dame Lesley Regan (former RCOG President); Dame Donna Kinnair (former RCN Chief Executive).
• The families fear this was a deliberate attempt to ensure the remaining preferred candidate, Baroness Amos, would be appointed.
• Amos has told some families that “she did not understand” that there wa a commitment to co-produce the investigation team with victims.
• When formally addressing the families, Amos has used insensitive language i.e., “families who ‘feel’ they have been let down.”
• Failures in cooperation and broken commitments by the DHSC have contributed to compounded harm and re-traumatisation for families, undermining Streeting’s assurance that they were “going to do it with them [the bereaved and harmed families], not to them.”

Conflict of interest:

• A statutory public inquiry would operate independent of the DHSC and could examine the Department’s own role and decisions. By contrast, the rapid review is overseen within the same system whose national maternity policy and oversight decisions are in question.
• If the rapid review’s scope extended to all things that needed to be looked at in depth, including the role of regulators, other bodies and royal colleges, it would have been essential for the investigation to be a public inquiry.
• Despite the families stressing the importance of scrutinising regulators, NHS England, and NHS Resolution in the investigation, this key point remains excluded from the terms of reference.
• The review is therefore limited in its ability to scrutinise systemic failures at a national level, and to establish accountability.
• The review is staffed by people who have been part of the systemic failures that have allowed babies to die therefore cannot be independent, particularly those who have worked for the DHSC, NHSE, and HSIB.
• The families raised concerns about conflicts of interest among the investigation team, but they were dismissed.
• Kathryn Whitehill’s role in the investigation poses a significant conflict of interest in that she is a former CQC inspector, which the families expressed “raised serious doubts about whether the review can be independent or trusted.”

The Chair’s dubious independence:

• The Chair of the Review, Baroness Amos, is a Labour peer with prior professional links to the Health Secretary’s partner, Joe Dancey, who previously worked as her special adviser and now acts as the government’s Director of Policy and Communications.
• Baroness Amos’ connection to Dancey undermines the Review’s purported arms-length-distance from the DHSC and the governing party.
• Baroness Amos’ career in government and diplomacy does not provide clinical or specialist expertise in maternity or neonatal care, raising concerns about her ability to oversee a review into serious clinical failures.

Redundant Interim Findings:

• The interim findings published by Baroness Amos in December 2025, 6 months after the rapid review was announced did not introduce new evidence, provide causal analysis, or set out recommendations for implementation or reform.
• Instead, they largely reiterated broad well-established themes, including that care for women and families continues to fall below acceptable standards and that many feel unsupported.
• This raises concerns that the final report will similarly lack the depth required to support enforceable evidence-based reform of the 12 Trusts.

Failure to meet minimum standards for a Rapid Review:

• Rapid reviews are effectively systemic reviews with shortcuts; trading depth for speed but this only furthers the expectation that they maintain systematic rigour.
• WHO’s explicit guidance on rapid reviews must have systemic and transparent processes with clarity about how evidence will be identified and synthesised.
• The published Terms of Reference setting out its aims, scope and evidence sources does not amount to a clear methodology for the review and uses terminology that is not medically or legally correct, and therefore unclear.
• The government’s official policy document published in September 2025 states that the detailed methodology “will be published in due course”, but this has still not transpired.
• Inclusion and exclusion criteria for evidence are not defined, and there is no transparent hierarchy for explaining how different types of evidence are weighted (e.g. lived experience vs. clinical data, or Trust-provided data versus independent sources).
• Data analysis methods are not explained nor are its limitations.
• The introduction of approaches part-way through the review - such as the nationwide ‘Call for Evidence’ - indicates that the methodology is being expanded retrospectively, rather than following a predefined robust methodology (Moons, et. al, 2021).

The Family Panels:

• The bereaved and harmed family panels arranged as part of the investigation are based on an allocation of 8 minutes per persons.
• According to the families engaged, the family panels are not well attended and one of the attendees explained that only 8 families were present at their panel.
• This limited involvement of the families shows that they have not sought out victims of harm in what were framed as panels for co-production with families.

Call for Evidence - National Survey:

Announced on Tuesday 20th January - deadline 17th March 2026

• Available to all women who have been pregnant and those supporting someone through pregnancy.
• This survey massively expands the evidence base mid-process without an explanation of how responses will be verified, analysed, weighted, or integrated alongside other evidence sources.
• Closing dates for family evidence and staff submissions is March with the Report due in spring. Given that it took months to organise a chair, how can they possibly do a substantive review of all evidence submissions in less than a month?
• The Call for Evidence involved the filling in of an online form, with a very limited word count which excludes most bereaved and harmed families from sharing the account of what happened to them.

Social media responses to the Call for Evidence announcement:

[Twitter / X]

-            “I supported the maternity investigation. But yesterday’s “call for evidence” makes one thing clear, this process is already failing the very families it claims to centre. Bereaved parents are being asked to compress trauma, loss, and systemic neglect into boxes and word limits. This is not how a system serious about learning behaves. It is how a system protects itself. Sanitising grief into forms strips out context, emotion, and responsibility and turns catastrophic failure into something administratively manageable.” @Tim_TaylorSmith (Link to thread)

-            “The evidence call from the Amos review is as good as a Reddit thread. All anonymous with no verification that you are someone who used maternity services and you can submit as many responses as you want. How is this evidence of anything other than incompetence from the review?” @catherineroyuk (Link to thread)

-            “What’s insane to me is this call to evidence that the national review has published. There is zero security. The same people could fill it out multiple times and they wouldn’t know. How can they be confident they are getting the full picture and an accurate reflection of the state of maternity. I’m sure this will just be another failed exercise because we will never be able to trust the results when half of them could be faked@wesstreeting surely it’s review 101 to make sure the call for evidence is accurate.” @babylossmummy (Link to thread)

-            “I am not the first to say it, I won’t be the last, but I tried to complete the survey and couldn’t. A 500-word limit to place on lifelong trauma, medical negligence resulting in multiple complex disabilities and lives changed forever is utterly unacceptable. Not only does this minimise and trivialise the horror experienced by women in maternity services in the UK, it doesn’t even give enough space to accurately describe what happened. It feels like the simplest of “survey monkey” style polls. There is no security, no verification, if I were less honest, I could complete the survey a dozen times with entirely false data, there isn’t even a verifier as to whether respondents live in the UK now or in the past. This. Will. Not. Help.” @RevdCharlotte (Link to thread)

-            “Trying to fix maternity services with an internet survey certainly tells its own story about how seriously preventable deaths, injuries and harms are being taken.” @drruthannharpur (Link to thread)

-            “I have learnt that there is a very, very fine line between “co-production” and abuse. And the absolute golden rule is nobody is asked to share their pain, their trauma, their valuable and personal data unless you can swear that it will be used for a meaningful purpose and not just to tick a “lived experiences collected” box.”@LucyGoBag (Link to thread)

ENDS

All media enquiries and interview requests should be directed to:    
natalierodgers@scala.uk.com, RebeccaFinley@Scala.uk.com and ArchieLeahy@Scala.uk.com 
T: 0114 4070159