Baroness Amos has provided an update on the investigation, sharing that what she has seen so far "has been much worse" than she'd anticipated and nothing prepared her for "the scale of unacceptable care that women and families have received, and continue to receive."

The investigation team have met with over 170 individual families and visited several of the sites which are included in the local investigations. The issues which Baroness Amos has heard include: 

• Women not being listened to or given the right information to make informed choices at critical moments of their care as risk profiles change.
• Women's knowledge of their own bodies and important information essential to clinical decision making about their care, such as reduced fetal movement, sometimes being disregarded.
• Fathers and non-birthing partners feeling unsupported.
• the impact of discrimination against women of colour, working class women, women with mental health challenges and younger parents leading to poorer outcomes.
• Lack of family engagement in reviews of care and feedback of review reports.
• The failure of regulatory bodies to protect vulnerable women and families and the perception of health professionals and organisations 'marking their own homework'.
• Women and families being placed in inappropriate spaces after loss or harm, for example, being put on wards with newborns after they have experienced a loss. 

These are issues which Sands and bereaved parents and families have been saying for years. Responding to the update, Sands Chief Executive Clea Harmer said: 

We were devastated by Baroness Amos' statement on the current state of affairs in maternity and neonatal care in England. It is deeply sad and frustrating to hear what Sands and bereaved parents and families have been saying for years. 

We know that listening to parents helps save lives. And we will continue to stand side-by-side with bereaved families and do all we can to make sure governments and NHS decision-makers hear their voices. 

However, it's clear that recommendations on their own change nothing. 

What is needed is wholesale systemic change, not tweaks to the current system. And this needs to be driven by determined leadership. Families deserve nothing less.  

 

Next steps: 

Baroness Amos has confirmed that: 

• A Call for Evidence for families will be launched in January 2026, and open for 8 weeks.
• A second update on the initial findings will be published in February 2026.
• The final report and recommendations will be published in Spring 2026. 

We will provide more information on the Call for Evidence when it launches.