Listening to patients and families 

If there is one theme that unites these reports more than any other, it is surely the importance of listening: something that is, indeed, a wider theme of patient safety reports across a range of settings. All too often, mothers and fathers described raising concerns about care, only for these to be dismissed – with the most devastating of consequences. In her 2026 review, Ockenden writes that “not listening to women [is] a common foundational failure… across all major maternity inquiries” (p. 83), and states plainly that “listening to women and families and acting promptly on concerns… might prevent future maternal deaths” (p. xiv). 

In response to the Ockenden and Amos reports, the Government has pledged to create a new role of “National Maternity Commissioner” to “provide independent leadership … [and] ensure the voices of women are always heard by those at the heart of the system”. This is, on the face of it, a positive step: the role is the first of eight key recommendations in the Amos report. A national figurehead could serve as a powerful champion for the voices of mothers and families, helping to embed a culture of listening and learning. 

But the proposal has not been universally well-received. Emily Barley, the co-founder of the Maternity Safety Alliance, has argued that focussing on a single role is unlikely to achieve systemic change. Ensuring that people are listened to in everyday care requires changes in culture and practice in maternity and neonatal wards across the NHS. The question, then, cannot be about a single role – but the overall architecture that enables listening to happen and that responds when it fails.  

The system for hearing people’s voices 

This is where things become more complicated, because changes to system architecture set out in the Dash Review and Ten Year Health Plan have the potential to blur accountability and could be seen to send mixed messages about how change will be driven. 

The new Maternity Commissioner will join a system that already includes a number of other national roles that bear similar duties and responsibilities. England already has a Patient Safety Commissioner who serves as “an independent champion for patients… ensuring that patient voices are at the heart of the design and delivery of healthcare”. The government also has a national Maternity Adviser, appointed in May 2026, who will “work directly with families… to push for better, safer care for mothers, babies, and families”. And, as set out in the Ten Year Health Plan, NHS England and the Department of Health and Social Care (DHSC) will soon add a National Director of Patient Experience, responsible for overseeing the development of patient voice. 

At the same time, much of the existing infrastructure to support independent patient voice locally is being removed via the Health Bill. The planned closure of Healthwatch England and its 153 local bodies will remove statutory duties for independent organisations to promote patient and public voice in local areas. The impression is that patient voice may be gaining traction at the centre of the health system, but with an uncertain path to local areas. 

It is also notable that Amos has emphasised the importance of creating “cultures in our health services where people feel able to speak up”: coincidentally, this statement was made on the same day that the National Freedom to Speak Up Guardian’s Office closed its doors, its functions having been absorbed into NHS England and providers. It seems unclear why leadership around staff voice should be distributed at the same time that patient voice is being centralised – or, indeed, why national and local leadership should not coexist.  

Owning recommendations 

The Amos and Ockenden reviews are excellent, comprehensive reports – but frustratingly, many of the issues that they highlight are familiar. The problem, as the Dash review  noted, is not a lack of reports or recommendations but of a failure to take ownership. The creation of new national roles may help with this, but it is essential that they have clear and defined responsibilities and are set up to work collaboratively so that they can set clear direction and provide effective leadership. 

A greater concern is that a focus on national roles may be at the expense of local leadership. Few NHS providers have board level directors with responsibility for patient experience, and a requirement for each provider to appoint board-level ‘patient experience champions’ has prompted limited action. Without independent Healthwatch bodies operating locally, there is a danger that a very welcome national focus on patient voice is overwhelmed, within providers, by competing priorities like financial compliance and waiting list management. 

This is not to criticise any of the recent reviews or their authors – their work has been exemplary, not least because each has made a strength of listening to people who have experienced harm; doing so openly and compassionately; and learning from their experiences. A fundamental lesson for the health service is that it must adopt this model more widely – not just in the reviews and investigations that follow the most serious failures, but in its everyday practice.