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The record

Reviews

Each entry is one inquiry, investigation, policy review or national strategy. Open a review for the findings, the paraphrased recommendations, and the other reviews that share its themes.

Clear

6 reviews

2026Independent reviewPublished

Amos maternity investigation

Baroness Valerie Amos

Rapid independent investigation ordered after the 10 Year Health Plan commitment and meetings with bereaved families. Baroness Amos was appointed in August 2025. The investigation looked at 12 trusts and at the national maternity system, and published final reports and recommendations on 30 June 2026. One expert adviser, Dr Bill Kirkup, stood down on 22 June 2026 because he could not agree the wording of the conclusions on normal-birth ideology.

CandourDigital and informationEstates and the care environment+5
Maternity and neonatal
England
4 recommendations in this hub
2026Independent reviewPublished

Ockenden, Nottingham

Donna Ockenden

Independent maternity review led by Donna Ockenden, commissioned in 2022 and published on 24 June 2026. It looked at care from 2012 to 2025. More than 2,500 families and more than 800 staff contributed. The review identified potentially avoidable harm, failures of staffing, a failure to listen to parents, and a failure to investigate and learn. It made local actions and 18 immediate and essential actions for maternity services in England.

Bereavement careCulture and conductData and early warning+7
Maternity and neonatal
England
6 recommendations in this hub
2022Independent reviewPublished

East Kent maternity

Dr Bill Kirkup

Independent investigation into maternity and neonatal care in East Kent. It found repeated failures over more than a decade. Kirkup deliberately did not add a long list of new recommendations. He set out four areas for action and argued that the problem was implementation of what was already known.

Culture and conductData and early warningLeadership and boards+5
Maternity and neonatal
England
3 recommendations in this hub
2015Independent reviewPublished

Morecambe Bay

Dr Bill Kirkup

Investigation into maternity and neonatal care at Furness General Hospital. It found dysfunctional relationships between midwives, obstetricians and paediatricians, and a failure to investigate deaths properly.

CandourCulture and conductLearning from harm+3
Maternity and neonatal
England
3 recommendations in this hub