The Amos review of maternity and neonatal services in England

Baroness Amos has published her reflections and initial impressions stating that “nothing prepared me for the scale of unacceptable care that women and families have received, and continue to receive.”  She notes that a “staggering” 748 recommendations relating to maternity and neonatal care have been recorded by the NHS, the majority of which have been made in the last 10 years. The aim of her investigation is to develop national recommendations that will help ensure safe, compassionate care is delivered everywhere. Local investigations of maternity and neonatal services in 12 NHS Trusts, will assist in identifying systemic issues that need rectifying and will not consist of a formal evaluation of the performance of a Trust or its staff.

Issues

Baroness Amos highlights 19 issues which she has heard about “consistently”. They include:

• A lack of communication and support from clinical teams and organisations.
• Women not being listened to or given the right information to make informed choices at critical moments of their care.
• The desire for a more holistic approach to care with maternity and neonatal teams working together to maximise good outcomes.
• The impact of discrimination against women of colour, working class women, women with mental health challenges and younger parents, leading to poorer outcomes.
• A lack of empathy, care or apology both as part of clinical care and after things have gone wrong, with women feeling blamed and guilty.
• An overly legalistic, adversarial approach when concerns or complaints are raised.
• Women and families finding it difficult to access their medical notes (and notes being redacted or observations filled in at a later date).

Coronial investigation of stillbirths and compensation for clinical negligence

The investigation’s Terms of Reference included a review of the legal framework regarding the role of coroners in relation to stillbirths and compensation following harm caused by clinical negligence. The former was the subject of a consultation in 2023, but did not progress at that time. Currently, coroners’ statutory responsibility is limited to babies born alive.

Next steps

• A call for evidence will be launched in January 2026, asking women, families, fathers and non-birthing partners about their experiences.
• Visits to the 12 NHS Trusts forming part of the investigation will be completed in January, with a report on the initial findings of the investigation in February 2026.
• The final report is planned for publication in spring 2026.

Comment: Baroness Amos’ reflections echo the findings of other recent reports into maternity services, for example Donna Ockenden’s report  into Shrewsbury and Telford Hospitals NHS Trust and Dr Bill Kirkup’s reports into University Hospitals of Morecambe Bay NHS Foundation Trust and East Kent Hospitals NHS Trust.  Her comment on the sheer number of recommendations made has a parallel in an early workstream of the Thirlwall Inquiry into events at the Countess of Chester Hospital NHS Foundation Trust leading to the murder convictions of Lucy Letby. The workstream reviewed all NHS inquiries over the past 30 years to consider the extent to which recommendations had been implemented. Read more about the Ockenden and Kirkup reports in our insights here and here.

Safety & Learning (General)

Delayed diagnosis of cancer: thematic review of GP indemnity claims

NHS Resolution has published a thematic review of 105 closed and settled claims involving delayed diagnosis of cancer in general practice. The total cost of these claims (including costs) was in excess of £6 million.

Headline findings

These include:

• 53% of claims featured remote consultations.
• 24.8% of primary care claims had an associated secondary care claim. Patients under existing and multiple specialties experienced increased delays.
• In 40% of claims, cancer was diagnosed following routine referrals or emergency department attendance. Non-use of urgent referrals in diagnostic requests and referrals was a recurrent theme.
• 73.5% of claimants aged under 50 were female with higher rates of metastases at diagnosis.

Themes and key findings

The review identified three broad themes: diagnostic process; communication within the consultation and beyond; and patient power (or a lack of it).

These were broken down into the following findings:

1. Lack of diagnosis, differential diagnosis and diagnostic overshadowing;
2. Repeated attendance not seen as a system measure;
3. Lack of urgent referral for tests and specialty review;
4. Response to negative findings and non-response to treatment;
5. History taking in remote consultations;
6. Lack of recognition of recurrence of cancer risk as a potential diagnosis;
7. Management of patients under existing and multiple specialties;
8. Interdependency between primary and secondary care in cancer detection;
9. Gender disparities in early-onset cancer; and
10. Limited ability of patients to access specialties without GP support.

Next steps

The review concluded that the themes identified suggested a systems-improvement approach was needed including:

• Review of multidisciplinary training standards for remote consultation and triage;
• Configuration of digital and telephony systems to detect and flag repeat attendance across multiple healthcare interfaces; and
• Enabling patient escalation in primary care.

What this means for you: Although the review’s action points target national and systemic issues, there is learning to be gleaned at a practice level, not least the importance of decision-making around classification of referral by the GP.  In addition, the high percentage of cases with remote consultations highlights an increased need for comprehensive history taking and assessment when the patient is not physically present. The number of cases with both primary and secondary care elements emphasises the importance of good communication, timely liaison and suggests that full implementation of the electronic patient record will assist in supporting safer care.

Jess’s Rule – “three strikes and we rethink”

Jess's rule requires GPs to pause, reassess, and consider alternative diagnoses or escalate care if a patient presents three times with the same or worsening symptoms without a substantiated diagnosis. Sadly, Jessica Brady in whose memory the rule is named, died of undiagnosed adenocarcinoma. Many GP teams already apply a version of the Rule as routine practice, but NHS England (NHSE) and the Department of Health and Social Care (DHSC) felt that formalisation would provide a consistent structure “to support reflection and timely action.”

What this means for you: Practices already using the rule need do nothing more as NHSE have acknowledged its current use in general practice and confirmed that no additional training or materials are required for implementation. Practices who are not will need to design, implement and monitor a system to capture relevant cases. The conclusions of NHS Resolution’s thematic review of delayed diagnosis of cancer claims in primary care identified  lack of patient empowerment as a theme and suggested that one of the next steps to remedy this is enabling patients to escalate in primary care. This has echoes of Martha’s Rule (applicable at the moment only to secondary care, excluding maternity) which gives a patient, family member, carer or member of staff the right to request an urgent medical review if they feel a rapidly deteriorating condition isn't being addressed. Read more about NHS Resolution’s thematic review above and our insight on Martha’s rule.

Managing risks for electro-cardiogram interpretation when ST Elevation Myocardial Infarction suspected

A Health Service Safety Investigations Body (HSSIB) report identifies risks for ambulance crews interpreting electro-cardiograms (ECGs) when faced with a patient with suspected ST Elevation Myocardial Infarction (STEMI). The report’s findings highlight key issues relating to the ability of ECG equipment to recognise a STEMI, but also the crew’s ability to recognise the condition and the level of clinical support available to them during interpretation. Whilst ‘barn door’ STEMIs are usually easy to determine, a more subtle presentation can be hard to identify. The report describes the sad death from cardiac arrest of a 33 year old suffering from chest pain and vomiting where an elevated heart rate on ECG was attributed to anxiety, age and other stressors, rather than a STEMI. Two recommendations are made:

• Procurement - Ambulance Trusts should ensure equipment purchased is suited to their needs.
• Enabling communication between ambulance crews and Primary Percutaneous Coronary Intervention centres to facilitate shared decision making when a STEMI is suspected.

Safety & Learning (Maternity)

NHS Resolution Thematic Review - anal sphincter injury claims

NHS Resolution conducted a thematic review of 237 obstetric anal sphincter injury (OASI) claims between 2011/12 and 2021/22 in collaboration with the Royal College of Obstetricians and Gynaecologists.

Key findings:

• 58% of women’s injuries were graded as less severe than they actually were – most classified as 2^nd degree tears rather than 3^rd or 4^th degree.
• The average delay before correct diagnosis was nearly 10 months, during which time women suffered debilitating symptoms including faecal incontinence (80% of cases), pain (74%) and psychological trauma (47%).
• 81% of claimants had assisted births – 54% of all cases involved forceps.
• Only 65% of women received the recommended rectal examination before suturing.
• 19% of women required surgical repair of the anal sphincter – 12% needed a temporary colostomy.
• First time mothers accounted for 84% of claims.

Six priority areas for improvement were identified:

1. Safer assisted vaginal births – ensuring obstetricians are properly trained in instrumental delivery techniques and appropriate use of episiotomy.
2. Better supervision – providing adequate support for trainee doctors and midwives performing complex deliveries.
3. Accurate diagnosis – training all clinicians to perform systemic vaginal and rectal examinations using the ‘pill rolling’ technique.
4. Enhanced education – raising awareness of symptoms, risk factors, and the significant impact on women’s lives.
5. Awareness of complications – recognising rare but devastating complications like rectovaginal fistula.
6. Consistent pathways – developing national guidance for managing women with missed injuries.

Comment: OASI can be an unavoidable complication of childbirth. However, the priority areas identified including earlier recognition and proper repair, safer assisted births and better training in systematic examination techniques, should mean that the risk of OASI is reduced and “offer the best chance of good outcomes” when injury occurs. As with any clinical risk training, supervision, awareness and the use of pathways will play a vital role in ensuring safe and appropriate patient care.

Roll-out of Maternity Outcomes Signal System (MOSS)

MOSS is a new online system designed to detect potential serious incidents before they emerge. Retrospective analysis by NHS England demonstrated that MOSS would have detected signals in maternity units that later experienced serious incidents, including East Kent Hospitals NHS Trust, Shrewsbury and Telford Hospitals NHS Trust, Leeds Teaching Hospitals NHS Trust, and Nottingham University Hospitals NHS Trust. Signals are traffic light coded with amber as 95% confidence and red as 99%. Once a signal is generated, it is mandatory for the maternity unit to carry out a critical safety check within 8 working days and share action taken with regional and national teams.

Comment: MOSS was created by the NHS as a direct response to a recommendation in Dr Bill Kirkup’s ‘Reading the Signals’ report into maternity services at East Kent. The data and signals will be visible at Trust, Integrated Care Board (ICB), regional and national level. Spotting early warning signs by looking at data in “near real time” should help avert safety incidents and prevent harm. The aim is to ensure that concerns are acted on quickly and that oversight from ward to board and across every part of the system, is transparent. Read our insight to learn more about Dr Kirkup’s report.

Regulatory & Liability

Using AI in healthcare

The Medicines and Healthcare products Regulatory Agency (MHRA) has launched a call for evidence. The MHRA is considering new proposals for regulating medical devices that use AI. A National Commission has been set up which brings together experts from technology, healthcare, law, patient groups, the public, government and the NHS. The Commission will consider what the regulatory rules should be and make recommendations to the MHRA. The call for evidence covers:

1. Whether the UK’s framework for regulating AI in healthcare is sufficient.
2. How it might need to be improved to ensure fast access to safe and effective AI medical devices.
3. Approaches to checking safety once AI medical devices are in use.
4. How responsibility and liability are managed between different parties involved in the deployment of AI medical devices.

Comment: With the use of AI in healthcare developing at pace, the call for evidence is timely. At the moment there is no specific ‘AI law’.  From a liability perspective various issues arise, including who is responsible for any harm caused when a clinician is using an AI-enabled application. Who is liable if a product behaved in a way that wasn’t anticipated?  Might an NHS organisation face an argument that it has a non-delegable duty of care? What is the contractual liability and indemnity position? Read our insight to learn more about the potential liability issues around AI in healthcare.

How Capsticks can help

We are a market leader in the field of clinical negligence, with specialist clinical negligence defence solicitors advising on the resolution of clinical negligence claims, management of complaints and serious incident investigations, together with an innovative outsourcing service for claims’ handling. Our team are recognised as being legal experts in handling inquests and inquiries for clients across health and social care, insurance and emergency services sectors.