National report published examining maternity and neonatal services
Maternity and neonatal services
The Investigation by Baroness Amos conducted reviews of maternity and neonatal services in 12 NHS trusts, in order to identify issues affecting services across England and to inform the development of the national recommendations.
The reports for each Trust have also been published, including a report about University Hospitals Sussex.
The investigation spoke to women and families from across the country, each with their own personal and unique lived experiences. Staff working in different services and at different levels of seniority were also spoken to.
Key findings
There were consistent themes that emerged which included:
- Women not being listened to.
- Staffing levels that do not match demand.
- High demand on services, leading to delays, overcrowding and, at times, care decisions being shaped by available space and patient flow rather than clinical need.
- Leadership and executive teams who were aware of the challenges but were not always equipped with the skills, knowledge and capabilities to make the changes required.
- Response when things go wrong were sometimes slow or defensive.
- Inequalities across maternity and neonatal services were consistently raised
- Estates - across the 12 Trusts were examples of estates that were not fit for purpose.
- IT systems - Trusts are working with multiple IT systems that do not ‘talk to each other’ or are unable to share information.
Many positive experiences were also recorded including teams working well together, supportive colleagues and initiatives that are leading to positive changes and outcomes for women, families and babies. At each Trust, local improvements were seen that were delivering results, although more needs to be done. Many trusts have put in place improvement plans where improvements may not yet be consistently felt by women and families using the services.
Results for University Hospitals Sussex
- Women and birthing people described services that were difficult to access quickly.
- Families said that opportunities to intervene or escalate to senior staff were potentially missed.
- Many families described a lack of cohesive working.
- Families described repeatedly having to retell their clinical history.
- Support after bereavement or harm was widely described as insufficient, inconsistent, or absent.
- Families whose first language was not English faced additional barriers.
- There was wide variation in terms of the estates. Princess Royal Hospital was described as spacious, while parts of Royal Sussex County Hospital were described as inadequate.
- Staff spoke about low morale and capacity not meeting demand. There were also recruitment and retention issues in some areas.
- Staff across the Trust described inconsistencies in leadership and governance. They provided examples of strong local leadership alongside concerns about visibility, consistency and wider organisational support.
- Some families described positive experiences with staff and other families also described positive care where they felt listened to, particularly when interpretation was available and staff took time to communicate clearly.
- Across all four sites, were staff who are committed to providing good care amidst widespread negative media coverage in high-capacity sites with workload pressures.
The Trust has already steps to improve telephone triage and have also recruited more midwives and changed how they listen and learn when things do go wrong. But at the same time, they recognise that more needs to be done.
You can watch the response of Trust chief executive Dr Andy Heeps in response to the Amos report here.
In May 2026, then Secretary of State for Health and Social Care confirmed that an external review of the Trust’s maternity services will be chaired by Donna Ockenden.
Downloads
The following documents provide further detail and recommendations, nationally and for University Hospitals Sussex.