Press Release – July 2026
A prominent clinical negligence and inquest specialist has warned that a landmark review into England’s maternity services risks costing lives by completely ignoring evidence from coronial investigations.
The independent investigation into maternity and neonatal services in England, published by Baroness Amos, followed a government-ordered rapid review into deep-seated safety concerns. It arrived just one week after Donna Ockenden’s separate inquiry exposed systemic failures at Nottingham University Hospitals NHS Trust.
Sadie Simpson, an inquest specialist at leading law firm Ison Harrison, represents dozens of families affected by negligent maternity care, including those in the Ockenden review. She argues that bypassing coronial findings leaves a dangerous blind spot in NHS oversight.
Sadie Simpson said:
“The National Report highlights the shocking reality that too many families have endured for decades. Sadly, these findings are not new; report after report has identified the same recurring failings. What is astounding is the continued failure to learn from those mistakes and deliver the sustained change needed to keep women and babies safe.”
While Baroness Amos pressed the government to respond to its delayed 2019 consultation on referring stillbirths to coroners, the wider utility of inquests was excluded. Instead, the interim National Medical Examiner suggested that the coronial review processes can cause “defensiveness” among staff, highlighting a cultural resistance to outside scrutiny.
Crucially, the national report omitted Prevention of Future Deaths (PFD) notices. Research by Dr Georgia Richards, founder of the Prevention of Future Deaths Tracker, identified 29 maternal death PFDs between 2013 and 2023. Dr Richards’ call to include this data was rejected as outside the review’s scope.
Simpson argues that the current coronial system allows NHS trusts to avoid Prevention of Future Deaths reports by presenting their own internally developed action plans at inquests, despite any independent verification of whether the promised changes are effective, creating a system where underlying systemic failings may remain unaddressed.
Inquests are intended to be inquisitorial fact-finding investigations rather than adversarial hearings, and in practice there is no uniform national approach to how evidence is gathered or when Prevention of Future Deaths reports are considered. As a result, the depth of scrutiny can vary considerably from court to court. However, Simpson argues that given that an inquest is often one of the first investigations into concerns about care, failures to obtain and examine all relevant evidence can mean critical safety issues are missed, reducing opportunities to identify systemic failings and prevent future deaths.
This is compounded by a significant inequality of arms within the coronial process. Bereaved families have no automatic right to publicly funded legal representation, while NHS trusts are routinely represented by experienced legal teams. This imbalance can contribute to delayed, incomplete, or selective disclosure of evidence, with few meaningful sanctions available when disclosure obligations are not met.
Simpson believes the absence of a consistent national approach to the coronial service’s evidence gathering, combined with disparities in legal representation, risks limiting the effectiveness of inquests as a mechanism for learning and accountability.
Simpson said:
“There is a real opportunity for change, and this could be a pivotal turning point for maternity care across the country. If we genuinely want to learn lessons and prevent future deaths, we need to consider the evidence arising from every avenue of investigation and, crucially, from the coronial service. Inquests are uniquely placed to identify emerging risks and systemic failures, but only if they are supported by robust evidence gathering and meaningful scrutiny.
“Whilst I welcome the recommendations to improve maternity care across the country, I believe a vital opportunity to drive meaningful change has been missed. Prevention of Future Deaths Reports and coronial investigations must be considered as part of this review as a matter of urgency. These reports identify failings that have already caused avoidable deaths; to overlook them is to risk allowing the same mistakes to be repeated, with devastating consequences for more families.”
Currently, coroners lack regulatory power to enforce recommendations, and England has no national system to track PFD trends. With the Amos review recommendations carrying a 6-to-18-month implementation timeline, campaigners say immediate data is being ignored.
Simpson concluded:
“It is alarming that data and evidence already exists, which could inform immediate changes to help prevent future deaths, yet this information is not being acted upon nationally. Urgent action could and should be taken to include coronial investigations as part of the review, while the wider recommendations in the National Report are hopefully implemented over the next 6 to 18 months and beyond. The time to safeguard women and babies is now. The Government must start using Prevention of Future Deaths Reports and the coronial investigations with real purpose: to learn from recurring failings, drive meaningful change and save lives.”
