Homerton Healthcare, which runs Hackney’s maternity services, has rated itself amber on 9 of 10 national actions to make maternity care safer, councillors have heard.
The trust told Hackney’s Adults, Health and Integration Scrutiny Commission it is not yet fully implementing national safety recommendations, made after significant national concerns about maternity and neonatal care. They include the Amos Review and the Thirlwall Inquiry, which followed the Lucy Letby case.
The Amos Review led to a 10-point plan. Using a red, amber and green (RAG) rating, the trust rated itself green, or compliant, on only one point: post-death care. The other nine are rated amber, meaning they need further development:
- Martha’s Rule
- Voice, outcomes and Board action
- Dual Board accountability
- Amos into Action
- Inequalities
- 24/7 safety and responsiveness
- Homebirth services
- Humanity and candour
- Safe and effective triage
Homerton Healthcare NHS Foundation Trust recognised that “further improvement and evidence are required” in a number of the amber areas. It has submitted its progress to the national team and will resubmit a follow-up review in December 2026. Full compliance is not expected by then, but the trust will need to show progress and board oversight.
The trust has also reviewed its position against the 17 recommendations of the Thirlwall Inquiry. Its initial assessment suggests it is in line with many of them, particularly on safeguarding governance, escalating concerns, board-level oversight of safety, mortality review systems and organisational culture.
But a number of recommendations need further detailed review, formal gap analysis and guidance from national bodies. These include neonatal CCTV surveillance, insulin security arrangements, neonatal medical examiner arrangements and guidance on the Sudden Unexpected Death in Infancy and Childhood (SUDIC) protocol, for which revised, shortened guidelines are expected.
The trust is also waiting for more information on a proposed Suspicion of Deliberate Harm Protocol. A new mandatory one-page protocol, with two pages of guidance, is expected by March 2027. The Thirlwall Inquiry also recommended ring-fenced funding for neonatologist medical examiner support, which the trust will need to secure.
The trust’s key priorities include strengthening the voice of women and families, improving its analysis of data on ethnicity and deprivation, and improving triage. It is gathering more feedback from maternity service users, including through the Maternity and Neonatal Voices Partnership (MNVP) and the Friends and Family Test. It is also focusing on improving reporting on learning, candour and support after harm, and making sure feedback loops with families are in place.
In December 2026, reports on equity in stillbirths and emergency caesareans will go to the trust’s board, in line with the National Action Plan. Gina Short, Homerton Healthcare’s director of midwifery, told the commission: “We’re going to be doing a deep dive and reviewing all of our stillbirths from this year in the next board in December.”
While the trust has set up safeguarding governance, mortality review systems and speaking-up initiatives, further work is needed to fully embed all the recommendations. The report said national guidance and detailed evidence on implementation are still awaited in some areas, such as Martha’s Rule and formalising reporting on inequalities and patient feedback.
What is Martha's Rule?
Martha’s Rule, named after 13-year-old Martha Mills who died in hospital in 2021, gives patients, their families and NHS staff the right to request an urgent review if they are worried that someone’s condition is getting worse. It is being rolled out across all maternity and neonatal units in England, with full implementation expected by March 2028.
