The Amos Interim Review: What Does It Tell Us, and Does It Change Anything?

When the interim report of the national maternity and neonatal investigation was published, we asked three CHFG ambassadors and one of our trustees to share their reflections. Dr Jane Carthey, Human Factors and Patient Safety Consultant; Neill Thompson, Chartered Psychologist; Andy Collen, Consultant Paramedic; and Dr Lauren Morgan, Chartered Human Factors specialist and CHFG Trustee, between them bring a breadth of perspective that spans clinical practice, systems design, investigation methodology, and lived experience of maternity harm. What follows draws on all four of their responses to explore what the Amos review actually tells us, and the harder question of whether this time anything will change.

We have been here before

The most striking thing about reading the Amos interim report is the familiarity of it. Poor culture, ineffective leadership, workforce distress, racism, crumbling estates, fragmented IT systems: these are not new findings. They appear in the Ockenden report. They appear in Kirkup. They surface year after year in national staff surveys and in academic literature. The report itself acknowledges this openly, noting the continuing distress to families and great frustration to staff that the same issues keep appearing without being addressed.

Jane Carthey has been living with this reality longer than most. In August 2026, her family will mark thirty-six years since her niece died at five days old following an obstetrics disaster. Thirty-six years of reviews, recommendations, and renewed cycles of concern. She does not say this to seek sympathy, but to make a point that numbers and policy language can obscure: the cost of inaction is not abstract. It is carried by real families, across decades. “This cycle must stop,” she writes, and the weight behind those four words is considerable.

Andy Collen frames the same problem from a systems perspective. What the review describes, he argues, are not random or isolated failures but the predictable outcomes of systems that were never designed to be reliable. When capacity is constrained, culture is fragile, and accountability is inconsistent, harm becomes not just possible but likely, regardless of the skill or commitment of the individuals working within those systems. The problem is the design, not the people.

Leadership: the symptom, not the cause

Leadership failure runs through the Amos review as a central theme, and all four contributors engage with it, though from different angles. Neill Thompson is direct about what the report shows: clinical leaders too often lack the time, training, and support to do their jobs effectively, and the consequences ripple outwards into culture, teamwork, and ultimately patient safety. The recent NMC spotlight report found four in ten midwives reported bullying or abuse from managers in the past year. That is not a collection of individual failings. It is a systemic pattern.

But Neill also makes a point that is easy to miss in a report focused heavily on what has gone wrong. Buried within the Amos review are examples of leadership that worked: wards and units where strong clinical leadership produced genuinely positive experiences for both staff and families. Neill’s argument is that these should not be footnotes. They should be the focus. Understanding what made those environments possible, and removing the barriers that prevent others from reaching the same standard, is arguably the most practical takeaway the report offers.

Jane adds an important dimension here. She cautions against the assumption that better leadership alone can fix what is broken. Even the strongest, most principled leaders, she argues, will be ineffective if the systems around them are poorly designed. The structures governing professional conduct, for instance, are shaped by national legislation, regulatory standards, and institutional processes that sit well beyond any individual leader’s control. Calling for stronger leadership without addressing the design of the systems leaders are working within risks producing yet more expectation without the means to meet it.

The human cost of a broken culture

The workforce picture in the Amos review is, as Lauren Morgan puts it, difficult. Midwives hiding their uniforms in public. Staff telling the review they feel embarrassed to say what they do for a living. Burnout commonplace. Incivility witnessed by patients and families in the spaces where they are at their most vulnerable.

Lauren draws on the patient safety literature to make a point that deserves wider attention: shame does not build safer systems. It builds secrets. When staff cannot speak about what is happening without fear of consequence, the conditions for learning from failure simply do not exist. This is not a soft concern about staff wellbeing sitting alongside the harder work of safety improvement. It is the same concern, viewed from a different angle.

Neill reinforces this by identifying incivility specifically as a human factors issue, one that affects not just staff morale but patient safety directly. Patients and families who witness poor staff relations experience real distress. That distress is not incidental. It is a measurable effect of cultural failure on the people in the room.

Andy notes that for all the complexity of the review’s findings, the solutions to cultural problems will not come from yet more training programmes or awareness campaigns. They require what he calls psychological and psychosocial safety for staff, underpinned by properly resourced services and modern investigation processes that prioritise learning over blame.

Racism as a safety issue

Both Lauren and Andy are emphatic on this point, and it is worth stating plainly: the racism findings in the Amos review are among the most serious it contains. Behind the statistics are individual accounts of pain being dismissed, of stereotyping shaping clinical decisions, of formal complaints being raised and receiving no meaningful response. This is a system failing the people receiving care and the people delivering it simultaneously.

Andy argues that racism and discrimination cannot be treated as peripheral concerns or addressed through standalone equality initiatives. They are, he writes, core determinants of safety, and any response to the review that does not treat them as such will be incomplete. Lauren goes further in her expectation of the final report, arguing that it will need to be explicit about what structural accountability looks like. 

The physical and digital environment

One of the areas where the Amos review breaks some new ground, or at least gives greater prominence to issues often treated as secondary, is its attention to the physical and technological environment of maternity care. Rooms too small for the equipment they need to contain. IT systems that cannot speak to one another, creating dangerous gaps in clinical information.

Lauren makes a practical suggestion that is worth highlighting: the co-location findings, which link the physical proximity of services to better teamwork and safer care, should feed directly into a formal update of NHS Health Building Notes. Similarly, the findings on IT fragmentation should be explicitly referenced against NHS Digital Clinical Safety Standards in the final recommendations. These are not bureaucratic details. They are the mechanisms through which findings get translated into the built environment and the digital infrastructure that clinicians actually work within.

Jane identifies the same territory through a human factors lens, noting that the review’s findings point clearly to the need for better workload assessment tools, improved IT usability, and a thorough review of past recommendations using system-focused rather than person-centred models.

So what happens next?

This is the question on which all four contributors, in their different ways, converge. And it is where the cautious optimism that runs through parts of their reflections gives way to something more guarded.

Jane is the most direct. The plan to establish a National Maternity and Neonatal Taskforce to develop an action plan informed by the review’s findings prompts her to note, with understandable weariness: “A taskforce? An action plan? We have been here before.” Her concern is not with the intent behind such structures but with the track record. Assurance-seeking processes that generate reporting requirements disconnected from genuine improvement have preceded this review. They must not follow it.

Lauren frames the stakes in terms of what the process itself means for the families who have contributed to it. They have shared painful experiences at considerable emotional cost, on the understanding that something will finally change. The final report, she argues, has an opportunity to model the compassionate engagement it identifies as lacking in maternity services. For that to happen, it must deliver not just recommendations but a genuine framework for healing alongside them.

Andy calls for actionable standards, sustained national coordination, and a commitment to implementing changes that are evidentially grounded. Not a new campaign. Not another cycle of diagnosis without delivery. Something that is actually, measurably different.

The Amos review has named the problem clearly, and it has done so with the benefit of testimony from families and staff whose courage in sharing their experiences should not be underestimated. The question of whether that clarity will translate into the kind of structural, interconnected change our contributors describe is one that only the final report, and the response to it, can answer. Families who have waited thirty-six years, and those who have waited far less but lost just as much, deserve nothing short of a definitive answer.