The appointment of a national maternity commissioner has been branded “fundamentally dangerous” by a bereaved mother who argues that handing sweeping powers to a single official will not fix a system she says has repeatedly failed to listen to women and families.
Emily Barley, whose daughter Beatrice died in 2022 because of failings at Barnsley Hospital, told BBC Radio 4’s Today programme that the recommendation for a maternity commissioner contained in Baroness Valerie Amos’s independent review was “not going to do what we need to move maternity safety forwards”. Barley, who co-founded the Maternity Safety Alliance, said concentrating responsibility for turning around maternity services in one person was “insane” and “not achievable”, and appeared “designed to me to grab headlines, but not to make the change that we need”.
Why the commissioner is ‘fundamentally dangerous’
Barley’s criticism cuts to the heart of a debate over how best to address long‑standing failings in maternity and neonatal care in England. She told the BBC that none of the recommendations in the Amos review would have prevented her daughter’s death, and that a pattern of women not being listened to – which Baroness Amos herself highlighted – persists even after a tragedy. “We’re finding now that even after our children have died, we’re still not being listened to,” she said.
She repeated her call for a full statutory public inquiry into maternity care failings, arguing that local investigations and the new commissioner role would be insufficient to achieve the necessary change. Her view is shared by many bereaved families and campaign groups who say only a public inquiry can uncover the full truth, establish accountability and deliver sustainable solutions. Some have expressed concern that the Amos investigation was not sufficiently independent and did not scrutinise regulators such as the Care Quality Commission and the General Medical Council.
Other critics have highlighted what they see as the limitations of the Amos review itself. The Birth Trauma Association described it as a “huge missed opportunity” for failing to address the impact of forceps deliveries, post‑traumatic stress disorder and the psychological effects of traumatic births. Dr Bill Kirkup, who chaired inquiries into maternity scandals at Morecambe Bay and East Kent, resigned from the Amos review over a dispute about “normal birth ideology”. Campaigners also point out that numerous recommendations from previous reviews have not been implemented, creating a sense of déjà vu and undermining confidence that new measures will be effective.
The government’s response and the new commissioner
James Murray, the Health Secretary, announced the government’s decision to create the UK’s first commissioner for maternity and neonatal care on 29 June 2026, in direct response to Baroness Amos’s government‑commissioned inquiry. The role is intended to pursue hospitals over persistent failures, ensure wide‑ranging improvements are made and restore the faith of families in a maternity system that has been rocked by a series of scandals at trusts including Morecambe Bay, Shrewsbury and Telford, and East Kent. The commissioner will co‑chair the National Maternity and Neonatal Taskforce alongside the Secretary of State.
Alongside the appointment, the government committed to publishing a national action plan by December 2026, an additional £41 million to improve safety at maternity and neonatal facilities, new standards for maternity triage to end the “postcode lottery” of care, the national rollout of the Perinatal Equity and Anti‑Discrimination Programme, and the creation of 1,000 temporary roles for newly qualified midwives backed by more than £10 million in funding.
Responding to Barley’s criticism on the same BBC programme, Baroness Amos rejected the suggestion that the commissioner would concentrate too much power in one person. “This is not about concentrating power in the hands of one person,” she said. “It is about saying that you need an independent voice and advocate for women and families.”
However, some campaigners and families have questioned whether the commissioner will be “meaningfully independent” and fear a “vacuum of leadership and action” once the initial attention fades. The scale of the challenge is underlined by the cost of childbirth‑related negligence claims, which reached almost £6 billion in compensation in 2023, with £2.6 billion paid out for clinical negligence relating to maternity care in 2022‑23 alone.
Recommendations of the Amos review
Baroness Amos’s investigation, launched in July 2025 by the then health secretary Wes Streeting, examined services at 12 NHS trusts and gathered evidence from thousands of women, families and staff. Its final report, published on 30 June 2026, concluded that the maternity and neonatal system in England is “no longer fit to consistently deliver high‑quality, compassionate care to every woman and family” and requires “urgent reform”. Among the key problems identified were a widespread failure to listen to women, poor care, a lack of accountability, racism and discrimination “embedded throughout the maternity and neonatal system”, understaffing, a “toxic and bullying culture”, a lack of senior medical presence on wards at night and weekends, and a fragmented system that left women facing a postcode lottery of care.
The review made eight main recommendations, four of which were highlighted in the government’s response. The first calls for an urgent overhaul of maternity triage services – the childbirth equivalent of A&E – including more staff on duty so that women’s concerns are acted on more quickly. The second would give families the right to seek a fresh, independent investigation when things go wrong if they are not satisfied with the hospital’s own inquiry. The third demands that the NHS replace its “brutal” and “cruel” system of agreeing compensation with harmed and bereaved families by a new process in which hospitals admit errors immediately. The fourth requires the NHS to root out racism and discrimination that the report found to be embedded throughout the system.
Appearing on BBC Breakfast, Baroness Amos said the culture of maternity services needed to change so that staff understand how to deal with trauma and feel able to speak up when something is going wrong, without being shut down by more senior colleagues. On the question of a statutory public inquiry, she told the Today programme it was her personal view that such inquiries take too long and that the changes she is proposing could have a transformational impact if started now, while acknowledging that she understood why some families continue to call for one.
The stark statistics that underpin the review’s urgency include the fact that in 2020 more than 2,000 children under the age of one died in England and Wales. Black women are almost three times more likely to die in childbirth than white women, and Asian women are twice as likely – disparities that the review’s recommendations on anti‑discrimination are intended to address.