The National Maternity and Neonatal Investigation (Amos Report) Explained for Medicine Interviews

The National Maternity and Neonatal Investigation was an independent review of NHS maternity and neonatal care in England, led by Baroness Valerie Amos. Her final report, published on 30 June 2026, made eight recommendations. For medicine interviews, it's a clear example of why listening to patients, speaking up and teamwork matter for safety.

I'm Dr Akash Gandhi, an NHS GP and the founder of TheUKCATPeople, and I've helped students prepare for medicine interviews since 2012. The Amos report draws together several maternity scandals you may have read about, and its lessons apply to every doctor. It sits alongside the other topics in our NHS hot topics guide.

What was the national maternity investigation?

The national maternity investigation was a rapid, independent inquiry into why women and babies in England were still coming to avoidable harm after years of reviews. It examined 12 NHS trusts in detail and the maternity system as a whole, and the final report and each trust report are on its website. The key facts:

• Ordered by: Wes Streeting, then Health and Social Care Secretary, on 23 June 2025, after a series of meetings with bereaved families
• Led by: Baroness Valerie Amos, a former Cabinet minister and senior United Nations official, chosen because families asked for someone with distance from the NHS
• Where it applies: England only, because health is run separately in Scotland, Wales and Northern Ireland
• Who it heard from: over 450 families, more than 10,500 responses to a public call for evidence and over 9,000 staff

Neonatal care means care for newborn babies, such as help at birth and support that keeps mothers and babies together. The timeline below is most of what you need to remember.

Key Takeaway: Say it was an independent national investigation led by Baroness Amos, that it reported on 30 June 2026, and that it made eight recommendations.

Why was the national maternity investigation set up?

It was set up because one local maternity scandal after another had found the same problems, and those problems kept coming back. Since the mid-2010s, the independent reviews of individual trusts have included:

• Morecambe Bay (2015): an investigation chaired by Dr Bill Kirkup into maternity and neonatal care at University Hospitals of Morecambe Bay
• Shrewsbury and Telford (2022): Donna Ockenden's review, which we cover in detail in our guide to the Shropshire maternity scandal
• East Kent (2022): also chaired by Dr Kirkup, published as Reading the signals
• Nottingham (2026): Donna Ockenden's review of Nottingham University Hospitals, published on 24 June 2026, six days before the Amos report

These reviews kept finding the same themes: women going unheard, weak leadership and teamwork, and too little learning from deaths and harm. In December 2025, Baroness Amos noted that the NHS had recorded 748 recommendations on maternity and neonatal care, most of them made since 2015, so the question was why so much advice had produced so little lasting change.

When I teach this topic, I compare it to a patient who keeps coming back with the same symptoms. If the same problem appears in hospital after hospital, the cause probably sits in the wider system.

Does this mean it isn't safe to have a baby in England?

No. Baroness Amos was clear that the vast majority of pregnancies and births in England have a positive outcome, and stillbirth and neonatal death rates are at or close to historically low levels, though progress has slowed since 2020. Her concern is that care varies too much, and that too many families have come to avoidable harm.

Key Takeaway: Explain that the investigation was set up because the same failings kept appearing in different hospitals, so the answer had to be national.

What did the Amos report find?

The report's central finding is that women and families are too often dismissed and unheard, and that this sits alongside racism and discrimination, poorly connected services and a system that doesn't put safety first.

• Women unheard: women described being dismissed when they raised concerns, staff disagreeing in front of them, and communication too poor for informed consent
• Racism and discrimination: stereotyping, racial slurs, Islamophobia and antisemitism, with real effects on safety, covered in the next section
• Fragmented care: GP, antenatal and postnatal care were poorly joined up, so women had to repeat painful information to different people again and again
• Triage under strain: triage, where a pregnant woman with a worry phones or arrives to be assessed, is becoming the A&E of maternity care but is under-resourced for that job
• Buildings and IT: cramped, poorly maintained units and computer systems that can't share information

Staff described the same system from the inside. They spoke of burnout, rota gaps, long shifts without breaks and a fear of being blamed, and told the investigation that empathy and compassion could be 'the first thing to go' under that pressure.

That phrase stayed with me, because every clinician recognises a shift where there's no time to sit down with a worried patient. It's why the report treats staffing and culture as safety issues, right alongside the experiences of families.

Key Takeaway: Lead with women being unheard, because it's the theme the report returns to most, then link it to racism, poor connections between services and pressure on staff.

What did the Amos report say about racism and inequality?

The report found that racism, discrimination and structural inequality make maternity care less safe, and that Black and Asian women and their babies have persistently poorer outcomes. The figures it quotes from national data are stark:

• Maternal deaths: between 2022 and 2024, the maternal mortality rate was 2.7 times as high for Black women as for White women, and 1.3 times as high for Asian women
• Stillbirth: babies from Black ethnic backgrounds are more than twice as likely to be stillborn as White babies
• Deprivation: maternal mortality was twice as high in the most deprived fifth of areas in England as in the least deprived fifth
• Being heard: in the call for evidence, 31 per cent of Asian respondents and 30 per cent from mixed ethnic groups agreed that staff listened to their concerns in labour, against 39 per cent of White respondents

Families described being stereotyped as more resilient, more tolerant of pain or more likely to exaggerate symptoms. The report found these assumptions could delay recognising that a woman was getting worse and reduce her access to pain relief.

Those listening figures are low for every group, so inequality sits on top of a problem that affects all women. It links to health inequalities and the Marmot Review, and to Black, Asian and minority ethnic staff in the NHS, many of whom told the investigation they feared speaking up about racism.

Key Takeaway: Quote one figure accurately, such as the 2.7 times higher maternal death rate for Black women, and explain how stereotypes about pain can delay care.

What are the eight recommendations of the Amos report?

The eight recommendations aim to redesign maternity and neonatal care around safety, led by a new national commissioner who answers to Parliament. The table below is most of what you need.

Some of the detail matters for future doctors:

• Continuity of carer: seeing the same midwife or small team for scheduled antenatal and postnatal care, plus a debrief offered to every woman after birth
• Triage: maternity triage becomes a safety-critical clinical area with binding national standards
• Senior cover: considering whether consultant obstetricians and anaesthetists should be available on delivery units 24 hours a day, seven days a week
• Training: a review of medical, midwifery and neonatal education, with more shared learning and with communication, teamworking and compassionate care at the centre

The report asked for the commissioner to be created through the Health Bill, the same bill that is set to abolish NHS England. It also listed actions that can start straight away, the most urgent being a board-level audit of every trust's triage service within three months.

Key Takeaway: You don't need all eight, but know the commissioner, listening to women, tackling racism and better teamwork, and be ready to say why each one matters.

How has the government responded to the Amos report?

The government responded on the day the report came out, 30 June 2026, with immediate measures and a promise of a full national action plan in December 2026. The announcement was made by James Murray, then Health and Social Care Secretary, and included:

• A Maternity and Neonatal Commissioner: the UK's first, to hold the system to account and co-chair the National Maternity and Neonatal Taskforce
• Money for buildings: an extra £41 million for safety problems in maternity and neonatal facilities, on top of £145 million committed since April 2025
• Tackling inequality: national rollout of the Perinatal Equity and Anti-Discrimination Programme across maternity teams
• Midwives: 1,000 temporary roles to help newly qualified midwives into NHS jobs

The next day, NHS England sent trusts a 10 Point Plan of urgent actions. It includes starting to roll out Martha's Rule across all maternity and neonatal services in 2026/27, so families can ask for a rapid independent review if they fear a mother or baby is deteriorating, and making medical directors and chief nurses jointly accountable at board level.

Yvette Cooper became Health and Social Care Secretary on 20 July 2026 and now chairs the taskforce writing the action plan. Some families have been critical from the start, telling Baroness Amos that only a statutory public inquiry would bring them justice.

Key Takeaway: Name the commissioner and the December 2026 action plan, and say that what matters now is whether the changes last this time.

What does the Amos report mean for doctors?

For doctors, the report's message is that listening, speaking up and teamwork are safety skills that sit right alongside clinical knowledge.

• Listening to patients: a woman's knowledge of her own body, such as noticing her baby moving less, is clinical information to act on, and good empathy and communication start there
• Speaking up: the report cites GMC data showing 27 per cent of obstetrics and gynaecology trainees were hesitant to escalate concerns, and our guide to whistleblowing in the NHS explains how concerns should be raised
• Teamwork: midwives, obstetricians, anaesthetists and neonatologists need shared goals and one clear message for the woman, which is the multidisciplinary team at work
• Saying sorry: families described slow, defensive responses and meaningless apologies, and being open when things go wrong is every doctor's duty

The same themes run through the Lucy Letby case and the Thirlwall Inquiry, where questions were asked about how concerns raised by staff were handled, and back to the Mid Staffordshire scandal and the Francis reports.

In my GP clinics I see women for their postnatal check six to eight weeks after birth. I've learned to ask how the birth felt as well as how the baby is, because it's sometimes the first time anyone has asked, and worries that went unheard on the ward often come out then.

Key Takeaway: Say that listening to patients and speaking up are safety skills, and give one example of each.

How can I talk about the national maternity investigation in my medicine interview?

The easiest way in is to connect the report's themes to something you've seen yourself, because listening and teamwork show up in every setting, from a GP surgery to a supermarket checkout.

• Work experience: a time a clinician checked that a patient understood, or a handover between staff that went well
• Volunteering or a part-time job: noticing when someone felt ignored, and what helped them feel listened to

Then give your answer a clear shape:

1. Say what the investigation was in one sentence, with the date and who led it
2. Pick the theme that fits the question, such as listening, racism or teamwork
3. Give one accurate fact from the report
4. Link it to something you've seen or done
5. Finish with what it means for you as a future doctor

Here's what interviewers are usually looking for:

• Awareness: that you follow what's happening in the NHS beyond the headlines
• Sensitivity: that you can talk about baby loss and harm with care for the families involved
• Reflection: that you can turn a national report into lessons for your own behaviour

Key Takeaway: Start from what you've seen, add one fact from the report, and end with what you'll carry into your own practice as a doctor.

What interview questions could come up on the Amos report?

You are unlikely to be asked any of these word for word, and you do not need a prepared answer to each one. Use them to check your understanding: if you could speak for a minute on most of them, you know this topic well enough for whatever the interviewer actually asks.

Questions to get you thinking

1. What do you know about recent problems in NHS maternity care?
2. Why do you think some women felt they were not listened to during pregnancy or labour?
3. Why might staff stay quiet when they are worried about a patient’s safety?
4. Why might Black and Asian women have poorer outcomes in maternity care?
5. What makes a good team on a busy ward?
6. Tell me about a time you saw someone being listened to well, or badly.

Harder questions to stretch you

1. So many reviews have made similar recommendations. Why do you think change has been so slow?
2. Some families wanted a full public inquiry. What are the pros and cons of a rapid investigation instead?
3. Should one national commissioner be in charge of maternity safety, or is it a job for each hospital?
4. On placement, a woman tells you she is worried about her baby but the midwife seems unconcerned. What would you do?

Model answer: "What do you know about recent problems in NHS maternity care?"

There have been several serious reviews of maternity care in England, including Donna Ockenden's reviews of Shrewsbury and Telford and, more recently, Nottingham. Because the same problems kept appearing, the government asked Baroness Amos to lead a national investigation, and her final report came out in June 2026.

The theme that stood out to me most was that women were often dismissed. Some raised concerns, for example about their baby moving less, and were not taken seriously, which in some cases led to avoidable harm.

The report also found that racism is embedded in the system. Between 2022 and 2024 the maternal death rate was 2.7 times as high for Black women as for White women, and families described stereotypes such as Black and Asian women being more tolerant of pain.

I think part of the problem is pressure on staff, because the report described burnout, rota gaps and a fear of being blamed. That does not excuse poor care, but it helps explain why adding more recommendations on their own has achieved so little. The report made eight recommendations, including a national commissioner and better ways of listening to women.

For me as a future doctor, the lesson is that listening is a safety skill. Volunteering at a care home, I noticed that residents became calmer when staff took a moment to hear what was worrying them. I would want to carry that into medicine, and to speak up if I was worried about a patient, even as a junior.

Why this answer works:

• It is accurate: it names the right people and the date, and uses one statistic correctly
• It picks a theme: it focuses on women being dismissed instead of listing every finding
• It is balanced: it recognises the pressure on staff while being clear that this does not excuse poor care
• It is personal: it ends with a lesson the student can apply to their own behaviour

Talking about baby loss out loud is harder than reading about it, so it's worth practising with someone who can give you feedback. Our medicine interview coaching offers mock interviews with personalised feedback, and there are plenty more questions in our medical school practice interview questions.

Key Takeaway: Give the background briefly, pick one theme, use one accurate fact and finish with what you'd do as a doctor.

The one thing to take into the room

The Amos report found that maternity care in England too often left women unheard, despite the same lessons being written down many times. If you can explain what it found, name a few recommendations and say what listening and speaking up mean for you, you'll be ready for most maternity questions.

For related reading, see our guides to Lord Darzi's investigation of the NHS, the NHS 10 Year Health Plan and the Care Quality Commission, or our wider NHS interview topics guide.

Key Takeaway: Listening to patients is a safety skill, and the Amos report shows why.