In this blog, Jessica Reeves, Head of Public Affairs and Campaigns details Sands’ evidence, recently submitted to Baroness Amos’ investigation.
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Sands argue that to improve maternity, neonatal and bereavement care in England we need whole-system reform, not just local service-level fixes. Despite years of inquiries and hundreds of recommendations, progress has stalled, inequalities persist, and bereaved families continue to experience preventable harm.
We highlight five areas where change is required:
1. Leadership, Accountability and Culture Change
Unsafe care is driven by poor organisational culture, ineffective leadership, and prioritisation of reputation management. Culture change cannot be achieved by a training course; it requires system wide reform.
We need a new national approach to ensure every trust delivering maternity and neonatal care embraces a “just culture” that is underpinned by justice, accountability and learning. Staff must feel safe to raise concerns and trust boards need clearer oversight.
A shared national definition of “safe maternity care” is required, with the Government taking national ownership of maternity safety and setting new targets to reduce rates of baby deaths to hold the whole system to account.
2. Structure of Maternity and Neonatal Services
Services are not currently designed around family’s needs with huge variation in experiences of care depending on where it is accessed. Previous recommendations have understandably focused on change within maternity departments. But there is a need to view the entire pregnancy and neonatal journey holistically with families at the centre.
Women, birthing people and their families must be at the centre of a system which has been designed to support and care for them at all stages of their journey. Bridging gaps between hospital and community care, ensuring staff have the right relational as well as clinical skills and that estates are fit for purpose are all essential.
3. National Standards, Implementation and ‘What Works’
The Sands and Tommy’s Joint Policy Unit has calculated that in 2022/23, 800 babies may have survived if care had been delivered in line with nationally agreed standards. Multiple reports and reviews over the last decade have resulted in over 700 recommendations, leading to confusion and variation.
Care must be evidence-based, with a clear focus on implementation. This will require evaluation of existing interventions and their implementation. Recommendations from all reviews and reports must be assessed, sequenced and prioritised. We need to understand what is driving local variation in adherence to best practice and how this can be overcome.
This will require strong national oversight. It is essential that services have the capacity, resources and support to be able to effectively do this. Requirements to implement something new must come with funding.
4. Eliminating Inequalities in Loss
Deep inequalities in baby loss by ethnicity and deprivation have been known for decades. Families face barriers to accessing care (interpreting, triage, costs, digital exclusion). Major data gaps exist for groups at higher risk of experiencing poor maternity and neonatal outcomes remain, including sexual orientation, gender identity and disability.
Systemic racism and discriminatory behaviours in maternity and neonatal services must be acknowledged and addressed. The current approach to tackling inequalities has not been sufficiently evaluated, properly monitored or consistent across different local areas. We need an evidence-based approach, with better data and insights and strong national oversight. The Government must introduce targets to eliminate inequalities in baby loss.
5. Bereaved Families’ Experiences of Reviews & Investigations
Current review and investigation processes are overly complicated, disjointed and difficult to navigate. Too often they exclude families’ experiences exacerbating their trauma. They also fail to deliver the learnings they were designed to with too little oversight from external parties.
Review, investigation and complaint processes need a complete overhaul. All investigations and reviews should be completed through a single parent pathway, which centres families and ensures accountability. This should join up seamlessly with complaints and feedback processes.
The experiences of bereaved families are central to our submission. Baroness Amos has also emphasised the importance of listening to bereaved families throughout the investigation, the final report of which is due to be published in June.