Two reports, One Message: What the Amos investigation adds to Ockenden
Within weeks of the Ockenden review of Nottingham, Baroness Amos has published the final report of her national investigation into maternity and neonatal services in England. As a doula trainer, I have read both. Here is where they meet, where they part — and what they mean for the families we walk beside.
By Alexandra Burner, Founder July 2026
At the end of June, Baroness Valerie Amos published the final report and recommendations of the Independent Investigation into Maternity and Neonatal Services in England. It landed barely a week after Donna Ockenden’s review of Nottingham University Hospitals — the largest maternity inquiry in NHS history — and the two documents now sit side by side as the some of most significant statements about maternity care this country has produced in a generation.
I have spent much of the last few weeks reading both, first as a doula and only second as a trainer of doulas. And what strikes me most is not where they differ, though the differences matter. It is that two entirely separate investigations — one a forensic examination of a single trust, one a rapid national inquiry hearing from over 10,500 women, birthing people and families and more than 9,000 staff — arrived, independently, at the same beating heart: women were not listened to, and the failure to listen cost lives.
When two investigations, working separately at completely different scales, both conclude that not listening to women is a safety issue — not a courtesy issue — that is no longer an opinion. It is evidence.
Two very different kinds of report
It helps to understand what each report is, because they were never trying to do the same job.
Ockenden’s team examined more than 2,000 individual maternity cases and over 900 neonatal cases at one trust, grading the care in each, tracing failures through antenatal care, triage, labour, postnatal care and — hardest of all to read — care after death. It names what happened to real families in one place over thirteen years, and it does so in unflinching detail.
Amos is a diagnosis of the whole body - the NHS maternity system at large. Commissioned as a rapid national investigation in 2025, her team visited twelve trusts, analysed over 9,500 pieces of evidence, and — crucially — conducted a review of the hundreds of recommendations made by previous inquiries to ask the question every birth worker has been asking for years: why does nothing seem to change? Her answer is that the system itself is fragmented, overly complex, drowning in overlapping guidance, and too slow to learn. In her own framing, this report ‘joins the dots’.
So Ockenden tells us, in devastating detail, what failure looks like on the ground. Amos tells us why the ground keeps failing. Read together, they are far more powerful than either alone.
Where the two reports agree
The convergence between them is remarkable, and as someone who trains doulas, each point of agreement reads like a confirmation of what birth workers have witnessed for years.
Listening as a safety-critical act. Ockenden documented women whose concerns about reduced movements and emerging complications were met with false reassurance. Amos goes a step further and recommends that data on whether women are listened to must be captured as safety intelligence — reviewed through patient safety governance and escalated to board level. Listening is no longer framed as kindness. It is framed as clinical safety infrastructure.
Racism and inequality as a safety issue, not a side note. Ockenden found that most of the maternal deaths examined were of women living in the most deprived areas or women who were not white British. Amos names racism and discrimination — overt and structural, experienced by families and by staff — as a critical maternity safety issue requiring urgent intervention, with regulators expected to assess it as part of service safety.
Triage as the weakest link. Ockenden identified telephone triage as a point where women were risk-assessed poorly and discouraged from coming in. Amos recommends that maternity triage be formally designated a safety-critical clinical environment with binding national standards — including the requirement that any woman who remains concerned after a phone call must be offered a face-to-face appointment. Every doula who has ever sat with a client at 2am while she was told to ‘take paracetamol and call back’ will feel the weight of that line.
Culture, staffing and leadership. Both reports describe exhausted staff, bullying, invisible leadership and fear of blame. Both are clear that frightened, unsupported staff cannot give safe, compassionate care — and Amos is explicit that staff must be seen as part of the solution.
Care after loss. Ockenden exposed profound failures in bereavement and after-death care. Amos recommends trauma-informed psychological support as routine practice after harm — clearly demarcated from bereavement support — and a standardised neonatal palliative care model planned with families. Both reports treat loss not as an edge case but as a core part of maternity care that must be done well.
The failure to learn. Six critical external reviews preceded Ockenden’s at Nottingham alone. Amos reviewed the recommendations of every major inquiry and found them too numerous, poorly prioritised, underfunded and unevaluated. Both reports are, at heart, about a system that keeps being told and keeps not changing.
Where they differ — and why the difference matters
The real distinction is in the mechanism of change each proposes.
Ockenden’s recommendations are largely about practice and process: implementing Martha’s Rule so families can trigger an urgent second clinical opinion; a new national assessment tool for maternity services; grading care on how well teams listen and escalate, not just on outcomes; restoring psychological support for baby loss; tackling bullying and mandatory training gaps. They are actions a trust, a ward, a team can begin tomorrow.
Amos reaches for structure. Her headline recommendation is the creation of a statutory Maternity and Neonatal Commissioner, accountable to Parliament, reporting to families annually — a permanent, legally established champion whose entire role is to hold the system to account. Around that role she builds a Modern Service Framework: national minimum safety standards across the whole pathway from preconception to postnatal care, a redesigned workforce model with senior obstetric presence available around the clock, a specialist regulatory unit within the CQC, ten-year investment commitments for crumbling estates, a single digital record for every woman and baby, and an examination of a less adversarial compensation system so that families are not forced to fight for answers.
Put simply: Ockenden asks the system to behave differently. Amos asks whether the system, as currently built, is capable of behaving differently at all — and concludes that it is not, without redesign and statutory accountability. Neither approach is sufficient alone. Culture change without structural change evaporates; structural change without culture change is an organogram. We need both, and for the first time we have both on the table at once.
What doulas and birth workers should take from Amos
Beyond the headlines, there are recommendations in the Amos report that speak directly to our daily work, and I want to name them because they will shape the conversations we have with clients for years to come.
Continuity of carer for all scheduled antenatal and postnatal care. Amos recommends it plainly. Doulas have always known what continuity does for safety and trust — it is, in many ways, the thing we exist to provide because the system cannot.
An end to fixed ‘high risk’ and ‘low risk’ labels. Risk is to be assessed dynamically at every appointment, not stamped on a woman at booking. This is a profound shift in how families will be spoken to and about, and we should help our clients understand and use it.
A postnatal debrief for every woman. Offered by a midwife or trained clinician, as standard. So many of the parents we support carry unprocessed birth stories for years; this recommendation acknowledges that the story matters.
Antenatal education redesigned around reality. Amos calls for NHS antenatal education that honestly reflects induction of labour, caesarean birth and pain relief, co-designed with women and families, with proactive outreach to those from disadvantaged backgrounds. This is a quiet revolution in a single bullet point — and a validation of every antenatal educator who has refused to teach a fairytale version of birth.
National guidance on supporting women who decline recommended care. For the first time, there will be national, rights-based guidance on respectful, clinically safe care for women making choices outside standard guidance. Doulas sit beside these families constantly. Clear national guidance — done well, with birth workers and families in the room — could transform those conversations from confrontation into genuine shared decision-making.
Holding both reports honestly
I want to be careful, as I was when writing about Nottingham, not to turn either report into a stick with which to beat the people working inside maternity services. Amos is clear that most staff are committed to high standards and are themselves harmed — morally injured is her phrase — by a system that will not let them care the way they trained to. Both reports also record genuinely good practice: exceptional neonatal care, models like Family Integrated Care that put parents at the centre, improved bereavement facilities. The point of reading these documents is not despair. It is clarity.
And the clarity is this: everything doulas offer — unhurried education, a listening ear, continuity, advocacy that helps a family be heard rather than speaking over them — has just been described, by two of the most authoritative investigations in NHS history, as the substance of safe care. Not a luxury. Not an extra. The substance.
We will keep doing what we have always done: sitting with families through pregnancy, birth, fertility and loss, helping them understand their choices, hearing the worry beneath their words, and standing beside them so that no one walks through any of it unheard or alone. The difference now is that no one can say the evidence isn’t there. It is there, twice over, in black and white.
Note on sources: this piece draws on the final report and recommendations of the Independent Investigation into Maternity and Neonatal Services in England (chaired by Baroness Amos) and the Ockenden review of maternity services at Nottingham University Hospitals NHS Trust (June 2026). We encourage readers to consult both reports in full.